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Background: This report addresses the feasibility of virtual injection software based on contrast-enhanced cone-beam CTs (CBCTs) in the context of cerebrovascular lesion embolization. Intracranial arteriovenous malformation (AVM), dural arteriovenous fistula (AVF) and mycotic aneurysm embolization cases with CBCTs performed between 2013 and 2020 were retrospectively reviewed. Cerebrovascular lesions were reviewed by 2 neurointerventionalists using a dedicated virtual injection software (EmboASSIST, GE Healthcare; Chicago, IL). Points of Interest (POIs) surrounding the vascular lesions were first identified. The software then automatically displayed POI-associated vascular traces from vessel roots to selected POIs. Vascular segments and reason for POI identification were recorded. Using 2D multiplanar reconstructions from CBCTs, the accuracy of vascular traces was assessed. Clinical utility metrics were recorded on a 3-point Likert scale from 1 (no benefit) to 3 (very beneficial)., Results: Nine cases (7 AVM, 1 AVF, 1 mycotic aneurysm) were reviewed, with 26 POIs selected. Three POIs were in 2nd order segments, 8 POIs in 3rd order segments and 15 POIs in 4th order segments of their respective arteries. The reviewers rated all 26 POI traces - involving a total of 90 vascular segments - as accurate. The average utility score across the 8 questions were 2.7 and 2.8 respectively from each reviewer, acknowledging the software's potential benefit in cerebrovascular embolization procedural planning., Conclusion: The operators considered CBCT-based virtual injection software clinically useful and accurate in guiding and planning cerebrovascular lesion embolization in this retrospective review. Future prospective studies in larger cohorts are warranted for validation of this modality.

Purpose: The purpose of this study was to report the technique for intraprocedural guidance of endovascular Venous Sinus Stenting procedures using 3-Dimensional (3D) Magnetic Resonance Venography (MRV) as an overlay on live biplanar fluoroscopy., Materials and Methods: Venous sinus stenting procedures performed between April and December, 2017 with 3D MRV fusion for live guidance were reviewed in this study. A thin-slice, contrast-enhanced MR Venogram was used to create 2 3D models - vessels and skull - for procedural guidance via augmented fluoroscopy (Vessel ASSIST, GE Healthcare, Chicago, IL). The skull model was used in the registration of the 3D overlay on both the frontal and lateral planes, which required 1-2 min of procedural time. The vessel model was used to mark landmarks such as the cortical vein ostia and stenosis on the 3D overlay fused with biplanar fluoroscopy. The retrospective imaging review was conducted by 3 neurointerventionalists and relied on a consensus confidence ranking on a 3-point Likert scale from 1- low confidence to 3- high confidence. The neurointerventionalists first reviewed the conventional 2-dimensional pre-stent deployment fluoroscopy images and then reviewed the corresponding images with the 3D MRV overlay. They ranked their confidence in their understanding of cortical venous anatomy for each group. Statistical analysis was performed using a Paired T Test at a 99% confidence interval., Results: Ten cases were included in the retrospective image review. Operator confidence regarding the location of cortical veins was significantly increased using 3D MRV fusion during venous sinus stenting procedures (1.9 vs 2.9, p = .001)., Conclusion: 3-Dimensional MRV fusion is feasible and helpful in understanding the venous sinus anatomy and location of important cortical veins during venous sinus stenting procedures.

Purpose: Pre-procedural contrast-enhanced CT and MRI imaging is typically acquired prior to deep venous recanalization procedures for post-thrombotic syndrome. This technical note reports the utility of live-overlay of augmented centerlines extracted from pre-procedural CT and MRI imaging in facilitating fluoroscopic-guided recanalization of post-thrombotic venous lesions., Methods and Materials: Six patients with pre-procedural CT or MR venography data were incorporated into a commercially available 3D overlay software (Vessel Assist, GE Healthcare, Buc, France) during venous disease interventions for post-thrombotic venous lesions. Procedures were performed on the GE Discovery IGS 740 fluoroscopy system. After manual determination of the vasculature from preprocedural CT or MR, centerlines were created representing the location and trajectory of the vessels. Steps showcasing the creation of centerlines and their representation during overlay with real-time fluoroscopic guidance in these cases are outlined. Time required to cross the post-thrombotic and occlusive venous segments were reviewed., Results: All iliocaval recanalization procedures were successfully performed utilizing vessel centerline 3D overlay. In one case where occlusion extended to the femoral vein, mis-registration was identified over the femoral anatomy due to a complex leg rotation compared to pre-procedural imaging. No procedural complications related to utilization of software were noted. Average crossing time for occlusions was 3.4 min (range 1.6-5.2)., Conclusion: 3D overlay with vessel tracking from pre-procedural CT and MRI imaging is technically feasible and assists in catheter navigation for post-thrombotic venous segments. While results from these preliminary experiences support the continued use of this technology, further prospective and comparative evaluation of this technique is warranted to assess for added value in technical success, reductions in procedure time or reductions in radiation exposure.