01 White Paper No.

02/2009

First Experiences with the Ziehm Vision

FD Mobile C-Arm with Flat-Panel Detector

Leiden University Medical Center (LUMC)

in the Netherlands is the first hospital in
the world using the Ziehm Vision FD in
clinical practice. Since the beginning of
2006, Dr. van der Linden and Dr. Willems-
sen from the Department of Radiology
have been working with this leading-
edge C-arm system in a clinical envi-
ronment. This technologically ground-
breaking new product was awarded the
“Product Innovation Award 2006” by
Frost & Sullivan on September 18, 2006.
Fig.1: Ziehm Vision FD

Ziehm Imaging has taken mobile C-arm imaging
to a new level by introducing the Ziehm Vision FD,
the first mobile C-arm in the world that
uses flat-panel detector technology. The Ziehm
Vision FD‘s cutting edge technology paves the
way for mobile C-arms to advance from purely
fulfilling applications in the operating theater to
undertaking the most advanced interventional
radiological procedures. The Ziehm Vision FD
features a flat-panel detector based on amor-
phous silicon (a-Si) photodiode technology with
a field size of 20 cm x 20 cm. The flat-panel
detector provides an unmatched dynamic range
with an image quality suitable for a wide
variety of different interventional radiology
procedures.
The compact design enables better patient
access and increased mobility, so that the unit
can easily be brought to the patient instead of the
patient to the unit. The system runs with a pulsing
generator featuring Vision Pulse technology run-
ning at a frame rate of up to 30 frames/sec in
fluoroscopy mode as well as in DSA or cine loop
modes. The user interface offers an intuitive
workflow and logical guidance using two synchro-
nized TFT touchscreen control panels, one con-
veniently mounted on a swivel arm of the C-arm,
the other one mounted on the monitor cart.
Why use a mobile C-arm with digital flat-panel
detector? We asked Dr. van der Linden and
Dr. Willemssen at LUMC in the Netherlands. “We
wanted to have a compact, high-quality C-arm
for OR procedures such as EVARs and simulta-
neously a mobile high-quality angiography sys-
tem as a backup here in our Radiology Depart-
ment. We also intended to use the unit for
CT-guided interventions in combination with X-ray
fluoroscopy instead of CT fluoroscopy for biop-
sies, catheter placements and vertebroplasty in
order to lower the dose levels. Besides, we were
also very curious to explore further practical ap-
plications opened up by this groundbreaking
technology. It was our intention to do some
research in this area”, says Dr. van der Linden.
02 White Paper No. 02/2009

Initial Experiences Case 1: Skeletal Intervention

Dr. Willemssen explains further about the clini-
cal experiences with the Ziehm Vision FD in daily
practice. “The C-arm has been in our depart-
ment since January 2006, and we have used it for
many vascular and non-vascular examinations
with excellent results. The unit provides high-
quality images with outstanding contrast reso-
lution. We used the C-arm for abdominal EVARs,
iliac stent placements, biliary PTAs, catheter
placements, biopsies and different skeletal in-
terventions such as arthrographies and verte-
broplasties. Normally, we run the unit at a pulse
rate of 15 pulses/sec, and at 5-10 pulses/sec
during catheter placements for further dose
savings.”
A 10-year-old boy presented with pain in the
right foot, especially when standing on his right
heel. Clinical examination revealed a normal
flexion and extension. Pronation and supination,
however, were decreased compared to the other
foot. An X-ray (Fig. 2) of the foot revealed a large
osteolytic lesion in the calcaneus, with sclerotic
margins. During the CT examination blood-fluid
levels were present. The diagnosis of aneurys-
mal bone cyst was confirmed. Due to pain
and diminished function, treatment was re-
quired. Earlier arterial embolization was un-
successful. Hence direct puncture into the bone
tumor was performed under CT guidance (Fig. 3)
using Ethibloc ® for the embolization.

“The unit is very easy to use and to manoeuvre

thanks to its compact detector dimensions and
smart touchscreen user interface – features that
are highly appreciated by our radiographers. The
C-arm opening is larger than on a conventional
C-arm, thus providing substantially improved pa-
tient access. The C-arm movements are not mo-
torized though. This functionality might be taken
into consideration for future improvements, al-
though it is not a must, as the C is very easy to
position anyhow,” adds Dr. Willemssen.

“From our experiences, there is no disadvantage Fig. 2: X-ray of the left foot showing large lytic
compared to an X-ray C-arm with image intensi- lesion the calcaneus.
fier. On the contrary: the image quality having
such excellent contrast resolution particularly
in DSA is a great improvement. The field size of
20 cm x 20 cm, however, entails some limitations
in the coverage of the lower extremities.”

Case Highlights from LUMC

“We would like to highlight some cases where
the Ziehm Vision FD performed especially well
compared to conventional C-arm systems”, says
Dr. Willemssen.

Fig. 3: Axial CT image of the embolization

shows the needle placed into the tumor as
well as the embolization material.
03 White Paper No. 02/2009
Fig. 4: Ziehm Vision FD image: the tumor is
clearly visible with good detail, as is the needle
and the embolization material.
Fig. 5: Lateral fluoroscopic image shows the
collapsed third lumbar vertebra with 2 needles
placed in it. The small needle is the RFA needle
and placed in the center of the tumor.
Fig. 6: Lateral fluoroscopic image shows the
distribution of cement into the fracture of the
vertebra.
Since one compartment was not embolized, a
second needle was placed into the tumor. The
injection of the embolization material was mon-
itored using the Ziehm Vision FD (Fig. 4). The
system‘s pulsed fluoroscopy mode ensured low-
dose radiation.
Case 2: Skeletal Intervention
A 61-year-old woman presented with pain in the
lumbar spine. The medical history revealed inva-
sive bladder carcinoma. X-ray of the lumbar spine
showed a collapsed third lumbar vertebra with a
fracture, highly suspicious of a pathologic frac-
ture. Histological biopsy confirmed the diagnosis
of vertebral metastasis. Since the patient experi-
enced a great deal of pain, she was referred to
the Radiology Department for radio frequency ab-
lation and vertebroplasty of the collapsed metas-
tasis vertebra.
We use the Ziehm Vision FD in our single-plane
angiography room to create a biplane system with
simultaneous antero-posterior and lateral pro-
jections. Such a combination is very convenient
and time-saving for this type of procedures, elim-
inating the need for rotating the X-ray tube as-
sembly constantly from the A.P. to lateral position
and vice versa. The Ziehm Vision FD is
ideally suited for this task. Due to its compact
dimensions and wide C-arm opening, the surgeon
benefits from ample space to perform the proce-
dure. The Ziehm Vision FD is used for obtaining
the lateral fluoroscopic images.
We also use this system for CT-guided vertebro-
plasty. The images obtained using lateral fluo-
roscopy are the most crucial, and are perfectly
visualized with the Ziehm Vision FD (Fig. 5, 6, 7).
04 White Paper No. 02/2009
Fig. 7: Lateral fluoroscopic image shows the
cement placed into the vertebra at the end of
the procedure, located in the center of the
vertebra. No leakage is noted.
Fig. 8: Angiogram during placement of the stent-
graft. Highlighted the marker indicating the be-
ginning of the covered part of the stent-graft. This
marker must be placed below the renal arteries.
Fig. 9: Coronal contrast-enhanced CT MIP image
2 days after placement of the stent-graft: the covered
part of the stent-graft is placed below the renal
arteries, with normal enhancement of the kidneys.
Case 3. Vascular Intervention
A 68-year-old male with diabetes (type II) had
presented with an aneurysm of the infrarenal ab-
dominal aorta and right iliac artery for more than
10 years. The dilation of the aneurysm had been
only slightly progressive in those years. However,
an operation or intervention became necessary
this year. The patient underwent an endovascular
aortic aneurysm repair in the OR under radio-
logical control using the Ziehm Vision FD. A com-
pact and powerful mobile X-ray C-arm is of vital
importance when procedures like these are per-
formed in the OR, where no stationary angiogra-
phy equipment is available.
The stent-graft is placed just below the renal
arteries, in this case with suprarenal fixation
(Fig. 8).
Excellent image quality is essential for precise
placement of the stent-graft, and the proximal
placement is most critical. With adipose patients,
however, it may become difficult to obtain the re-
quired image quality level. Even then the Ziehm
Vision FD produced images of fine quality, thus
avoiding possible complications caused by lack
of visibility.
Conclusion
“Based on the various clinical experiences
we have had in the past few months, we find the
Ziehm Vision FD to be a powerful mobile C-arm
with high performance and superior image qual-
ity. It is a valuable tool as a mobile C-arm and can
be used beneficially for a wide range of
both vascular and non-vascular applications,”
summarizes Dr. Willemssen.
05 White Paper No. 02/2009
Product Innovation Award 2006
Frost & Sullivan, a renowned European analyst
and consulting house, honoured Ziehm Imaging`s
pioneering mobile C-arm “Ziehm Vision FD” with
the “Frost & Sullivan Product Innovation Award
2006” on September 18, 2006.
The system features a groundbreaking digital
flat-panel detector that replaces the image in-
tensifier traditionally found on this type of X-ray
equipment. The high-dynamic detector enables
distortion-free digital capture of the finest bone
and soft tissue structures required, for instance,
in the area of neurosurgery or tumor localization
for radiation therapy. Entirely new fields of ap-
plication for mobile C-arms will open up when
combining the unit with navigation or Computer
Aided Surgery (CAS) systems.
With the introduction of the Vision FD, Ziehm
Imaging has taken a major leap forward in set-
ting the direction for the future of mobile
C-arms,” says Frost & Sullivan Medical Imaging
Team Leader, Karthik Arun B. “The Vision FD is
expected to set new standards for image quality
and patient safety as well as to expand the num-
ber of applications where mobile C-arms can be
used.” In presenting this award to Ziehm, the re-
nowned market research organization has rec-
ognized the trend setting technology which,
within a few more years, will be standard equip-
ment in every high-tech OR.