CARE+CLEARImproving image quality and optimizing dose in every Artis system.

Reducing dose in interventional procedures is increasingly important for both patients and clinical staff. In many cases, however, image quality is the key to successful procedures. A dilemma?

Now with CARE+CLEAR, our comprehensive portfolio of image-quality and dose-saving tools. Because every patient and every case is different, only you can decide on the image quality you need – and then determine the lowest possible dose. CARE+CLEAR supports you in making confident decisions in diagnosis and treatment and increases the safety of both your patients and staff. A Siemens exclusive: CARE+CLEAR is standard with every Artis angiography system. Unmatched since 1994.

Everything in life should be well balanced. We can support you in attaining a balance for your patients, you and your staff – with a perfect interplay of the optimal image quality and the lowest reasonable dose. The advantages are clear:

Scientific Publications

Cardiology

Effectiveness of Low Rate Fluoroscopy at Reducing Operator and Patient Radiation Dose During Transradial Coronary Angiography and Interventions (2014, Artis dFc)
Eltigani Abdelaal, MD, Guillaume Plourde, MS, Jimmy MacHaalany, MD, Jean Arsenault, Eng, MScA, Goran Rimac, MS, Jean-Pierre Déry, MD, Gérald Barbeau, MD, Eric Larose, MD, Robert De Larochellière, MD, Can M. Nguyen, MD, Ricardo Allende, MD, Henrique Ribeiro, MD, Olivier Costerousse, PhD, Rosaire Mongrain, Eng, PhD, Olivier F. Bertrand, MD, PhD
Link to Publication

Relationship of Beam Angulation and Radiation Exposure in the Cardiac Catheterization Laboratory (2014, Artis zee)
Shikhar Agarwal, MD, MPH, Akhil Parashar, MD, Navkaranbir Singh Bajaj, MD, Imran Khan, MD, Imran Ahmad, MD, Fredrick A. Heupler Jr., MD, Matthew Bunte, MD, Dhruv K. Modi, MD, E. Murat Tuzcu, MD, Samir R. Kapadia, MD
Link to Publication

Influence of flat-panel fluoroscopic equipment variables on cardiac radiation doses. (2007, Axiom Artis dBC)
Nickoloff EL, Lu ZF, Dutta A, So J, Balter S, Moses J
Link to Publication

Radiation dose reduction in the invasive cardiovascular laboratory: implementing a culture and philosophy of radiation safety. (2012, AXIOM Artis 60%, Philips Integris 40%)
Fetterly KA, Mathew V, Lennon R, Bell MR, Holmes DR Jr, Rihal CS
Link to Publication

Measures to Reduce Radiation in a Modern Cardiac Catheterization Laboratory (2014, Artis zee)
Shikhar Agarwal, MD, MPH, Akhil Parashar, MD, Stephen G. Ellis, MD, Frederick A. Heupler Jr, MD, Evan Lau, MD, E. Murat Tuzcu, MD and Samir R. Kapadia, MD
Link to Publication

Efficacy of a Minicourse in Radiation-Reducing Techniques in Invasive Cardiology
A Multicenter Field Study (2014, Artis zee)
Eberhard Kuon, MD,* Kerstin Weitmann, MSC,y Wolfgang Hoffmann, MD,y Marcus Dörr, MD,z Thorsten Reffelmann, MD,z Astrid Hummel, MD,z Alexander Riad, MD,z Mathias C. Busch, MD,z Klaus Empen, MD,z Stephan B. Felix, MDz
Link to Publication

Latest-generation catheterization systems enable invasive submillisievert coronary angiography (2013. Artis zee)
E. Kuon, K. Weitmann, A. Hummel, M. Dörr, T. Reffelmann, A. Riad, M.C. Busch, S.B. Felix, W. Hoffmann, K. Empen
Link to Publication

ECG-gated coronary angiography enables submillisievert imaging in invasive cardiology (2014)
Kuon E, Felix SB, Weitmann K, Büchner I, Hummel A, Dörr M, Reffelmann T, Riad A, Busch MC, Empen K
Link to Publication

Effective radiation dosage of three-dimensional rotational angiography in children (Artis zee, 2014)
Marjolein Peters , Gregor Krings, Michel Koster, Mirella Molenschot, Mathhias W. Freund , and Johannes M.P.J. Breur
Link to publication

Radiation dose reduction capabilities of a next generation pediatric imaging system (Artis Q.zen)
Luke Lamers, Martine Moran, Jenna Smith, John Hokanson
Link to publication

Electrophysiology

Practical ways to reduce radiation dose for patients and staff during device implantations and electrophysiological procedures (2014, AXIOM Artis)
Hein Heidbuchel, Fred H.M. Wittkampf, Eliseo Vano, Sabine Ernst, Richard Schilling, Eugenio Picano and Lluis Mont
Link to Publication

Interventional Radiology

Radiation dose reduction in fluoroscopic procedures: left varicocele embolization as a model (Artis zee, 2014)
Anthony G. Verstandig, Bashar Shamieh, Vladimir Shraibman & David Raveh
Link to publication

Uterine Fibroid Embolization (UFE) and Radiation Exposure in the year 2015: The potential for dose-reduction applying the new Siemens Artis Q technology. (Artis Q, 2015)
C. M. Sommer, M. Klapp-Oliger, A. Hatopp, S. Erpenbach, K. Thomas, P. Kurz, G. M. Richter
Link to Poster

Reference Levels for Patient Radiation Doses in Interventional Radiology:
Proposed Initial Values for U.S. Practice (2009)
Miller DL1, Kwon D, Bonavia GH
Link to publication

Interventional Neuroradiology

O-014 significant acquisition dose reduction maintains diagnostic quality of biplane cerebral digital subtraction angiography. (Artis zee, 2014)
Honarmand A, Shaibani A, Hurley M, Patel B, Daruwalla V, Ansari S
Link to publication

Patient radiation dose in diagnostic and interventional procedures for intracranial aneurysms: experience at a single center. (Artis zee, 2014)
Chun CW, Kim BS, Lee CH, Ihn YK, Shin YS
Link to publication

Dose reduction

CARE
As a leader in healthcare innovation, Siemens has a strong legacy in dose-reducing technologies. For many years we have been focused on reducing dose without compromising image quality and clinical outcomes. The philosophy behind our Combined Applications to Reduce Exposure (CARE) is simple: They are designed to help you deliver better care at the lowest reasonable dose. These cutting-edge functions are designed to reduce radiation dosage for both patient and clinical staff to make dose monitoring and reporting easy and structured for the hospital.

CARE Benefits

Reduces patient and operator dose to a minimum
Provides dose monitoring during the procedure
Makes dose reporting easy and structured
The complete CARE package is standard with every Artis system

Dose saving

Advanced dose-saving technologies effectively reduce radiation dose for patient and operator.

Reduced operator exposure
Reduced patient exposure
Improves hospital marketing capabilities
Addresses a broader patient mix: dose-sensitive patients (e.g. children)

Read more about our dose-saving applications.

CAREposition

Based on the Last Image Hold (LIH), a graphical outline of the upcoming image is displayed on the monitor, allowing you to move the table or C-arm without any radiation. Because you can position patients without additional fluoroscopy, dose reduction is possible – making CAREposition an ideal choice for long procedures.

CAREposition reduces dose by omitting fluoroscopy while repositioning.

CAREvision

CAREvision enables variable fluoroscopic pulse rates ranging from 30 p/s to only 0.5 p/s, which can considerably reduce radiation exposure for patients and staff. When using 7.5 p/s instead of 30 p/s, for example, dose saving of up to 75% is possible – without losing image quality.

CAREvision drives dose reduction by adapting the frame rate.

CAREfilter

During digital acquisition or fluoroscopy, the variable filtration is set automatically according to the patient thickness and the angulation of the C-arm. By adjusting the filter size with CAREfilter, you can achieve up to 50% entrance dose reduction** – with minimal impact on image contrast.

Discover how CAREfilter with multi-thickness copper pre-filters for skin dose reduction works.

CAREprofile

Using the Last Image Hold as a reference, CAREprofile enables radiation-free collimator adjustment and semitransparent filter position setting. As a result, you can achieve dose savings.

CAREprofile enables dose reduction through radiation-free collimator adjustment.

Low-dose syngo DynaCT

With low-dose syngo DynaCT, you can perform 3D imaging at the lowest possible dose during treatment ‒ which is especially important for radiosensitive patients like children. You obtain excellent imaging results at only 0.1 mSv.

Low-dose syngo DynaCT combines excellent imaging results with substantial dose reductions.

Low-dose acquisition

Low-dose acquisition provides excellent image quality with a dose reduction of up to 67% in comparison to normal acquisition protocols. One acquisition pedal of the footswitch can be configured as a low-dose acquisition pedal.

Low-dose Acqusition provides the image quality you need a much lower dose.

Dose monitoring

With the dose-monitoring features, patient entrance dose** control becomes easy and efficient.

Better control of accumulated patient entrance dose**
Enhanced in-house dose reporting
Enhanced transparency regarding dose per case
Prepared for future standards, easier to meet required dose levels

Read more about our dose-monitoring applications.

CAREwatch

CAREwatch displays the dose area product and air kerma rate or air kerma* at the interventional reference point on the live display in the examination and control room.

CAREwatch makes dose visible on the live display for optimal dose management.

CAREguard

CAREguard provides an effective way to control the patient's accumulated air kerma*. Warnings are given on the live display monitor and touchscreen if the air kerma** exceeds one of the three predefined thresholds.

Watch how CAREguard increases the patients safety.

Dose reporting

State-of-the art reporting solutions enable efficient and transparent reporting and documentation of radiation dose.

Better patient dose exposure control and greater transparency
Advanced knowledge of when a report has to be written
Be at the ready when legal authorities ask for dose per case
Prepared for future standards

Read more about our dose-reporting applications.

CAREreport

At the end of each procedure step, CAREreport automatically creates a DICOM Dose Structured Report and transfers the dose values directly to your Hospital Information System. This information supports you in optimizing dose management for patients and procedures.

Watch how CAREreport facilitates dose management.

CARE Analytics

CARE Analytics presents the information of DICOM Structured Dose Reports in a table format for further analysis. So you can compare, for example, dose given during different examinations and the dose a patient has received on different imaging systems – even in other hospitals. This may result in dose savings.

CAREmonitor

CAREmonitor shows the accumulated peak air kerma* according to the current projection in the form of a fill indicator on the live monitor. When your predefined threshold is reached the system warns you and you can consider another C-arm angulation.

CAREmonitor provides real-time skin-dose monitoring during interventional procedures.

Image quality

CLEAR
Whether your patients are tall or short, obese or slender – you need to see. And in order to see, you need optimal image quality that helps you make the right decision for the patient. Our comprehensive range of CLEAR applications automatically enhances image quality and thus helps increase certainty during interventions without increasing the dose.

CLEAR Benefits

Achieves optimized image quality
Applies comprehensive image processing
Customizes the image display to preferences
The CLEAR package is standard with every Artis system

Optimizing image quality – Image acquisition

Advanced image acquisition features like a high-power X-ray tube and optimized brightness achieve excellent contrast when imaging obese patients and avoid overexposures.
Read more about our image processing applications.

CLEARpulse

With CLEARpulse and the use of an optimized X-ray spectrum, the pulse length can be shortened by 43 percent. This not only reduces dosage for the patient but also improves image quality and sharpness.*

CLEARcontrol

Using the unique histogram analysis, CLEARcontrol correctly exposes the entire image. By automatically enhancing the brightness, contrast and spatial resolution throughout the entire image, it provides better vessel visibility near the diaphragm.

CLEARcontrol - better vessel visibility through automatically enhanced image brightness

CLEARmap**

Achieving best possible image quality in Roadmap is crucial during complex interventions. CLEARmap enables enhanced image quality and functionality with less system interactions. Get more out of your system by simplifying your workflow, while saving dose and contrast.

CLEARmap - fast and easy access to enhanced image quality in Roadmap

Optimizing image quality – Image processing

Our features provide the entire range of real-time postprocessing tools needed to optimize the contrast and sharpness of the image without increasing the dose. Read more about our image processsing applications.

CLEARview

Using a unique dose-adaptive algorithm, CLEARview reduces the noise in low-dose images. It splits a raw image into its parts and removes the noise with multilevel decomposition. Then the image is reconstructed – and the result is a sharper image.

CLEARview enhances image quality in low-dose imaging

CLEARvessel

The algorithm of CLEARvessel works automatically in the background in real time to enhance the visibility of vessel edges. For each pixel, the system decides whether it’s part of the background or the vessel – and increases or decreases the contrast to smooth the image.

CLEARvessel improves image quality by enhancing visibility of the vessel edges.

CLEARmotion

Based on a unique algorithm, CLEARmotion automatically detects fine structures and compensates for motion artifacts. This means optimal visualization of small vessels, fine structures, and guidewires in every heartbeat.

CLEARmotion ensures excellent image quality with every heartbeat.

CLEARmatch**

Patient motion leads to decreased image quality. CLEARmatch keeps the live image while pixel-shifting the mask image in real-time to provide consistent image quality during Roadmap. Get sharper images and enhance your treatment even in challenging situations.

CLEARmatch - compensating for patient movement with next generation real-time pixel-shift

Customizing image quality

Every interventionalist has his/her own preference when it comes to image quality. Some like sharper images, some smoother. With the image presets, you can choose

CLEARchoice

With CLEARchoice, you can customize image quality to your individual preferences, whether you like smooth images, more contrast or less noise. Simply choose the image quality you want – independent of patient and dose.

See how CLEARchoice provides individually tailored image quality

Radiation Protection

In addition to protecting patients from excessive radiation exposure, physicians, technicians and other medical staff should be protected from unnecessary (i.e. scattered) radiation as well.
Care about your own safety and want to find out how you can reduce radiation exposure in addition to our CARE+CLEAR package? Here you can discover different ways of reducing radiation dose in the interventional lab.

Protect the operator

Radiation management for interventional fluoroscopy – staff safety.

Download brochure

Reducing radiation dose in the interventional lab.

Download poster

How to ... CARE

Part 1: AX dose saving

Reduce dose for the operator

Scattered radiation does not come directly from the X-ray tube, but rather is scattered by the patient, table, or other devices within the path of the X-ray beam. Usually most of the scattered radiation is generated where the X-ray beam hits the patient.

1. Collimate if applicable

Scattered radiation is approximately proportional to dose area product, that means 50% area translates into 50% scattered radiation (if dose = constant)! The collimation also results in an improved image quality (less scattered radiation, better contrast).

2. Stay away from the tube side

Scattered radiation can be reduced by installing the lateral C-arm with the tube on the left side of the table when the medical staff works on the right. Scattered radiation is mainly generated at the beam entrance location of the patient, which is on the left side in this configuration. At the operator’s working position (right side), radiation exposure from scatter is much lower.

3. Stay away from the patient

Scattered radiation is roughly proportional to the dose area product (DAP) and decreases with distance squared to the location the scatter is generated. That is, twice the distance results in a quarter of the scattered radiation.

4. Shield as much as possible

Scattered radiation is attenuated by matter. Typical shields:

Apron (lead)
Glass shields (lead)
Glasses (lead)
Lower/upper body protection
Body (tissue, bone)

5. Bring the monitor as close as possible

The optimal eye to monitor distance is 1 meter or less for non-zoomed display.

6. RaySafe i2 Builds a Better Radiation Safety Culture™

RaySafe i2 dosimeter system is indispensable in creating a successful radiation safety culture. Once in place, both healthcare workers and management benefit from the radiation insight gained. Moreover, focus is returned to treating patients, versus worrying about unnecessary radiation exposure.

i2 Dosimeter
An active dosimeter that measures and records radiation every second. Data is transferred wirelessly to the i2 real-time display. It is maintenance-free, easy to wear and can be personalized with different colors and names.

Protect the patient

Radiation management for interventional fluoroscopy – patient radiation management.

Download brochure

Reducing radiation dose in the interventional lab.

Download poster

How to ... CARE

Part 2: Artis specific dose saving

Reduce dose for the patient

1. Select the adequate protocol

For especially dose-sensitive patients, it is possible to generate a special low-dose acquisition protocol. An acquisition pedal of the footswitch can be configured as a low-dose acquisition alternative to the ECC/TSC. A dose saving of 67% can be achieved by using an acquisition dose of 80 nGy/f instead of 240 nGy/f for interventional cardiology and an acquisition dose of 0.8 μGy/f instead of 2.4 μGy/f for interventional radiology.

Choose a proper organ program
Use low dose acquisition
Use Fluoro Loop (Store Fluoro)
Use Low Dose 3D protocols

2. Minimize footswitch-on time

Footswitch-on time: footswitch-on time controls how long the beam is on the body and thus how long the body is irradiated; less time means less radiation.

Less footswitch-on time ⇒ less skin dose
Example: ½ time on the pedal ⇒ ½ skin dose, ½ dose area product

3. Use low frame rate

High frame rates are used to visualize fast motion without stroboscopic effects. However, the higher the frame rate, the more radiation. Therefore it is best to keep the frame rate as low as possible.

Lower frame rate ⇒ lower skin dose
Example: 7.5 vs. 15 fps ⇒ 50% vs. 100% of skin dose and dose area product
CAREvision: Individually adjustable frame rate from 30 fps down to 0.5 fps

4. Zoom out as much as applicable

Increase of zoom size ⇒ increase of skin dose
⇒ decrease of skin dose area product (only for open collimation)

Effect on image quality:
For large patients at dose rate limit: Increase of zoom size ⇒ increase of image quality
For small patients: Decrease of zoom size ⇒ increase of image quality

5. Lower SID as much as applicable

SID: according to the quadratic law and a constant requested dose at the detector, a greater distance between the source and the imager increases the patient entrance dose. Raising SID from 105 cm (= SID 1) to 120 cm (= SID 2) increases patient entrance dose (i.e. the dose at the IRP) by approximately 30%.

6. Remove grid and increase SID

“Air Gap Technique” (for small patients only, <20 kg)
A simple way to reduce the dose in pediatric examinations, especially for babies or very thin patients, when scatter radiation can be expected to be negligible, is to remove the scatter grid in the flat detector housing.
The grid factor (i.e. the absorption of primary radiation due to the anti-scatter grid compared to free air) is 1.35, which translates into a dose saving of 26%* when removing the grid.

7. Use shallow angles as much as possible

An increase in patient’s thickness of about 3 cm results in twice the entrance dose for a constant detector entrance dose. This rule of thumb is based on the assumption that tissue absorbs radiation in a similar manner as water and that a certain quality of beam is applied.

For every 3 cm patient thickness, entrance dose is doubled (for const. exit dose)

A similar effect occurs when the direction of projection is changed to an oblique position. Because the shape of the body is more oval than circular, the length of the X-ray beam is now longer, resulting in a higher entrance dose. True values may differ significantly since the body is not really a homogeneous ellipsoid but consists of bones, organs, etc.

Shallow angles ⇒ less skin dose

Customer Experiences

Care for practical, hands-on information about CARE+CLEAR? Here you can discover more about your colleagues’ experiences with Dose Saving and Image Quality in Interventional Imaging. Find out first hand about the advantages of our comprehensive portfolio.

Customer Statements

P. Vierbeck, A. Funk, H. Galluhn, R. Kügler, Endoscopy Technicians
Klinikum Altenburger Land, Altenburg

“Low-dose protocols in endoscopy and ERCP are very significant. We often use protocols at 0.81 μGy/image in 22 cm format (corresponding to 0.41 μGy/image in 48 cm format) and always pulsed fluoroscopy (CAREvision).”
“Adjustment of radiographic image possible without radiation exposure, ‘Super!’ (CAREprofile and CAREposition)”

Dr. Michael Repp, MBA

Klinikum Altenburger Land, Altenburg

“Using CLEAR technology, the system allows for working with the lowest possible amounts of contrast agent with simultaneously high detail recognition of the gastrointestinal tract, especially the pancreaticobiliary ductal system. At the same time the optimized gray scale resolution ensures safe positioning of implants in stenoses of the gastrointestinal tract through certain detection of the stent and its markers.”

Dr. Beate Faust-Herzog

Heinrich-Braun-Krankenhaus GmbH, Kirchberg

“An important aspect in gastroenterology is a non-overexposed fluoroscopy image reproduced 1:1 in the digital image.”

Prof. Ansgar Berlis

Klinikum Augsburg

"Manufacturers must look after the safety of both patients and medical staff. This type of safety system can determine whether or not a device is selected, which means that manufacturers must treat them as a quality criterion rather than offering them for an additional charge. Who would drive an automobile today without a seatbelt and an airbag?"

"We should be concerned about everyone’s well-being. And if we can generate better images using less radiation, then it makes sense for us to do so."

Prof. Thomas Albrecht

Vivantes Hospital Berlin

"I consider minimizing radiological exposure for the intervention personnel to be a matter of key concern. In this connection, progress in the area of device technology must be supplemented by observance of radiological protection measures by the staff."

Dr. Olaf Göing

Sana Klinikum, Berlin

"These days, when we have a better understanding of the connections between radiology dose and potential illness than we did previously, I think that features that enable us to reduce the dose of radiation should be provided as a matter of course. There should not even be the possibility of choosing differently just to cut costs."

"Protecting employees as part of our ‘constant activity’ in the cardiac catheterization laboratory cannot be rated highly enough."

"If I were buying a catheterization unit I would classify radiological dose-reduction features as a fixture, if the case arose. All other options depend on financial and medical necessity and can still be negotiated, unlike radiological protection."

Charles Mazzarese

Stony Brook Medical Center, New York

„syngo DynaCT and the integrated CARE feature make the task of keeping the dose low virtually effortless“

AX Care and Clear Testimonials Prof. Brachmann

Prof. Johannes Brachmann

Coburg Clinic, Coburg

“New image algorithms from recent updates deliver the best images we have ever seen.”

“Today images show a very homogenous contrast distribution, sharp vessel edges, and minimal background noise. Siemens has done a great job with image processing enhancements.”

Dr. Gerard O´Sullivan

University College Hospital Galway, Ireland

“There are certain differences which make the Siemens system in my opinion at least superior, specifically iGuide, the DynaCT, and the ability to pan to a specific position on the patient without using Fluoroscopy is a massive advantage. They seem like little things, but it´s an accumulative thing.”

Customer Video statements

Achim Büttner, M.D.

Heart Center, Bad Krotzingen

Aquilla S. Turk, M.D.

Medical University of South Carolina (MUSC), Charleston, SC

Olaf Göing, M.D.