A patient’s vascular system is as unique as their life. Constitutional or acquired vulnerabilities that lead to aortic diseases like aneurysm or dissection are a major challenge. A thoroughly and precisely planned intervention is a real game-changer for these patients. One approach is the digital twin concept embedded in a hybrid operating environment.
A collaborative approach for digital technologies
Antoine Millon, MD, has been working on ways to make treatments less invasive and more successful for years. As Head of the Vascular and Endovascular Surgery Department at Louis Pradel Hospital in Lyon, France, he is at the heart of a collaborative regional network that was created to improve vascular care across the Rhone Alpes Auvergne region.
Millon strives to build and maintain strong momentum – in his own department and beyond – by contributing to advancing research and innovation, especially in the field of digital technologies applied in the hybrid operating room during endovascular procedures. His personal credo: “Alone we go faster, but together we go further.” For many years, he has participated in a collaboration with PrediSurge, a spin-off company from the Center for Biomedical and Healthcare Engineering at Mines Saint-Etienne, which develops a digital twin concept: predictive software solutions for cardiovascular interventions.
The increased impact of endovascular services
Millon observes that the number and complexity of endovascular procedures has dramatically increased over the last 20 years [1]: “Endovascular aortic aneurysm repair (EVAR) is a very good example of this stunning evolution. Standard EVAR started in the late 1990s, and there were initially only very few procedures performed per year. Today it represents over 80 percent of elective repairs for infrarenal aneurysms in our department.”
In 2006, Louis Pradel Hospital began to perform complex EVAR and especially fEVAR and bEVAR. “At the beginning, there were less than ten cases per year due to the very steep learning curve and the lack of reimbursement for custom-made devices,” Millon recalls. Starting in 2012, the advent of reimbursement and a collaborative approach were key for increasing the procedure numbers. “Today we perform over 50 fEVAR/bEVAR interventions per year.”
Plan and anticipate instead of try and adjust
“Assessing the device’s behavior is paramount for procedural planning. Before the advent of digital twin technology, there was no dedicated tool available,” Millon says. “Device behavior was evaluated based on intuition and experience, which requires a high level of specialization.”
To design a device for fenestrated endovascular aortic repair, a standard workflow starts with an analysis of the preoperative CT scan by the physician, manufacturers, clinical specialists, and the planning center. “Initially, fEVAR planning was time consuming and labor intensive. The fact that there was no specific tool to evaluate the device’s behavior led to suboptimal accuracy in device design as well as device-related complications.”
"It took a lot of time to manufacture the stent-graft prototype. We had to perform a test in advance, but the rigidity and opacity of the plastic aorta model sometimes resulted in intraoperative difficulties,” Millon remembers.
“Suboptimal positions increased fenestration and target artery catheterization time – and that sometimes resulted in target artery injury or end-organ failure due to distal embolization. Secondary procedures to repair fenestration-related complications like endoleaks or stenoses were frequent,” Millon says.
Now the digital twin technology allows him to choose the optimal device dimensions and the position of fenestrations and therefore design an optimal strategy for each patient.
His team can now better plan the length of covered stents deployed across fenestrations, which can prevent complications like Type Ic endoleaks. “It’s like you can see the postsurgery CT before the intervention,” Millon affirms. The workflow is as easy as this:
"Having a predictive tool has dramatically changed my clinical routine, moving us away from the intraprocedural ‘try and adjust’, thanks to more planning and prediction before the procedure,” says Millon.
Lower radiation dose - better outcomes
Thanks to improved planning and guidance, patients at Louis Pradel Hospital benefit from “a simpler and more straightforward procedure with better clinical outcomes,” Antoine Millon points out. In his opinion, working in a hybrid OR increases precision because the team benefits from the best image quality with the lowest possible dose.
The ability to do a 3D CT scan at the end of the procedure is just one of many benefits of working in a hybrid OR that Antoine Millon describes. See what other advantages he experiences when performing complex aortic procedures:
Digital technologies for real progress
Today the team at Louis Pradel Hospital is enjoying the best of both worlds as their standard: The digital twin technology enables them to anticipate difficulties and adjust the device design preoperatively, and the robotic imaging system allows them to perform a highly efficient procedure. “ARTIS pheno delivers excellent image quality and guides the procedure from start to finish in a low-dose environment. The increased comfort and reduced radiation dose have decreased the intra and postprocedural complication rates for our patients,” says Millon. “There has been a real sense of progress for the entire team since we started using these technologies.”
I think that in the future the digital twin technology and the hybrid operating room will merge with the 3D planning prediction and preoperative guidance […] and we’ll be able to perform the procedure before we operate on the patient.
Interview with Antoine Millon about the future of vascular surgery
Will FEVAR with the digital twin become a state-of-the-art procedure in the future?
Antoine Millon: Definitely! But we’re witnessing the classic hurdles for any groundbreaking technology. The first is the lack of understanding about how the technology works. User confidence is paramount and needs to be increased through more communication of validation studies. Second, some physicians fear that they’ll be replaced by the technology, which isn’t true. The digital twin is a powerful tool, but it will remain a tool, not something that will replace a physician’s or clinical specialist’s judgment.
