Device can be used to treat aneurysms, other cases

Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be "The Informed Patient," with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. Surgeons at Upstate's heart and vascular center are using a new surgical navigation device for complicated cases. And here to tell us about it is Dr. Michael Costanza. He's a professor of surgery at upstate and division chief of vascular surgery and endovascular services. Welcome back to "The Informed Patient," Dr. Costanza.

Michael Costanza, MD: Thanks for having me.

Host Amber Smith: This device is an interoperative position system. Can you tell us what that is?

Michael Costanza, MD: This device is an alternative to using traditional X-rays, for finding the position of catheters in the body when we do a complicated procedure on the inside part of blood vessels. And what it does is it basically makes almost like a mini GPS (global positioning system) within that room that we do the procedures so that we can localize the catheters and the wires and the stents without having to use X-rays.

And the reason that's important is that X-rays are a form of radiation, which affects not only the patient but also all of the people that are in the room helping the patient. And, over time the buildup of radiation can cause other problems, such as cataracts and cancer and skin problems and things like that. So the more that we can minimize the use of that potentially harmful radiation with an alternative system that doesn't do that and is also even more accurate than just traditional X-rays, the better. And this is really a breakthrough in that type of technology.

Host Amber Smith: Does it look like an X-ray machine to a patient?

Michael Costanza, MD: So it actually involves an X-ray before the procedure in the form of a CT scan. And then once we get that, we load that into the computer, and then we create, like I said, kind of a mini electromagnetic field in the room, which all that involves is putting a kind of a sticker on the patient. And then we have a separate console that that shows the images from that.

Actually, the images come out as looking like 3D images, almost like a video game. But you can rotate the image in any dimension and see any angle that you need. And then you can also, because the catheters and the wires that we use have implanted chips in them, when we introduce those into the body, we can actually see that on the screen. So it's almost like a virtual reality situation, that far of a detail and that much spatial relationship.

Host Amber Smith: Does it make use of the same technology that our phones do, for the GPS so that you know the positioning?

Michael Costanza, MD: Yeah, exactly. It uses its own GPS system, so it's almost like having mini satellites within that room that localize everything and then merge it with the data from the CT scan so that we have the anatomic data from the patient and then the GPS data from the machine and the catheters and we fuse the two of them together, and that way we can see everything without having to go to X-rays or anything like that.

Host Amber Smith: So I know when you get an X-ray, the patient doesn't feel anything, per se. Do they feel this happening with the IOPS?

Michael Costanza, MD: Not at all. There's no external force at all. It's purely just a localization thing. Just like X-rays are an invisible force, this is the same way. So they don't feel anything. They don't have to prepare in any way. And nothing would seem different to them other than the long-term effects of not having that exposure to the extra radiation.

Host Amber Smith: Can you tell us about the types of cases that would be good for this system?

Michael Costanza, MD: Yeah. There's a lot of different applications. Right now they're primarily involved in complicated endovascular procedures -- which are the procedures that we do -- on the inside of blood vessels for a couple reasons. One is to take care of complicated aneurysms, which are abnormal enlargement of blood vessels. And, the aorta, which is the main blood vessel in the body, is the most common spot that happens.

And if that vessel starts getting larger and larger at some point, just like when you blow up a balloon, it reaches a certain tension before it breaks. If that blood vessel breaks, then that's a very bad, catastrophic event that usually most people don't survive.

So with this technology, we can go on the inside of the blood vessel, go to that weak area, and with this guidance we can put in a stent that seals off that part of the weak area above and below the weakness. And it often involves getting smaller branches to get smaller stents in so that they're not blocked by the main stent. And that's where this technology comes in because we can really see exactly where those branches are without having to subject the patient to long courses of radiation or that contrast material or the dye that people are aware of that is also potentially harmful in large exposures to the kidneys. So we can avoid all of that and still be able to very effectively locate these vessels.

Host Amber Smith: So are some of these cases done emergently?

Michael Costanza, MD: They are occasionally done emergently, but with the current technology, we really do need a pre-procedure CT scan. So in most cases these are scheduled cases, but I can see in the future that they're going to shorten the preparation time for these. So I think eventually we will be using this for more and more emergent cases. But right now they're scheduled.

Host Amber Smith: So you described how it would be used for an aneurysm. What about if there's a blockage or a clot or something? Is it useful for those circumstances too?

Michael Costanza, MD: It is, especially within the abdominal cavity. The kidney arteries and the arteries that go through the intestines can be notoriously difficult to get a catheter into because of their location and their small size. And with this technology we can easily find them and know that we're in the right spot immediately, because of the display images and that fusion of the patient data and the GPS together.

Host Amber Smith: I wonder how common this is used across the nation. Is this available in most hospitals?

Michael Costanza, MD: Yeah, surprisingly this is not available in most hospitals. We're one of about nine or 10 hospitals that have it currently. They're always trying to expand their reach, but it is relatively new technology and and I think it's kind of one of those innovations that's going to gain more traction. But fortunately, we were able to get on very early in the course.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith, and I'm talking with Dr. Michael Costanza. He's a professor Surgeons at Upstate’s Heart and Vascular Center are using a new surgical navigation device for complicated cases. Michael Costanza, MD, explains how this is used in a variety of cases, including aneurysms and occlusions. Costanza is a professor of surgery at Upstate and division chief of vascular surgery and endovascular services. Of surgery at upstate and division chief of vascular surgery and endovascular services, and he's telling us about the intraoperative position system.

Are there studies comparing the outcomes using this system with whatever you would've done before this was available?

Michael Costanza, MD: Yeah, they've done some studies looking at the time that it takes to do these complicated cases with the system, and it has decreased the time it takes by more than half, in the studies. So, you can imagine how that is good for everybody involved. The hospital uses less staffing. There's less radiation involved. The patients get out of the operating room sooner. And you can do more patients in one day, by cutting the time down so much.

Host Amber Smith: Well, let's talk about which patients would be suitable. Is there anything that would disqualify someone from having this?

Michael Costanza, MD: The only thing that would really keep somebody in the current setup would be if they could not have that preoperative CT scan, for whatever reason. But CT scans can be done on almost everyone. The MRIs are sometimes not available to all patients because of metal implants, or pacemakers, or things like that. But there's very few people that can't have a CT scan, so that would be the only thing. There's really nothing about the system itself that would prevent anyone from having it. There's no allergies involved or conditions that would prevent you from having it.

Host Amber Smith: Are there any risks that patients need to know about ahead of time?

Michael Costanza, MD: Really no risk involved in the procedure because it doesn't involve any radiation. And the system itself is not invasive. It's just there to guide the invasive part of it, and so, really, the greater risk is really to have traditional X-rays with the radiation involved.

If you really had a complicated procedure and had a prolonged exposure to X-rays, patients do run the risk of having complications locally and in the long term from that. But with this, because it doesn't use any radiation or any contrast, that really has minimized those risks.

Host Amber Smith: How do you advise patients to prepare for this procedure?

Michael Costanza, MD: There's no specific preparation for it. We usually talk to them about it beforehand because it does involve some positioning in the room and things, and we tell them that's going to happen. But it's nothing that they need to prepare for in advance.

Host Amber Smith: Are they asleep during the procedure or do they hear what's happening?

Michael Costanza, MD: It depends on the procedure. A lot of our procedures are done with just some moderate sedation. So they, so some of them are awake with it. And, what they see with that is just that the, we move the x-ray part of the machine out of the way and we bring in this monitor that we can just work off of. So that's the only thing that they would probably notice about the procedure itself.

The more complicated procedures that involve a longer time to do, then we would do those under anesthesia.

Host Amber Smith: And what is recovery like? How long are they in the hospital afterward?

Michael Costanza, MD: Well, these procedures are all minimally invasive because they're on the inside of the blood vessel. And so the nice thing about those are that the recovery time is very, very short. And, many of the procedures can be done on an outpatient basis. They would go home the same day. And then some of the more complicated ones, we usually bring them in overnight, just to monitor them. But then usually it's not more than a day in the hospital because we're able to use needles and catheters rather than scalpels and incisions, it really makes a big difference of recovering faster.

Host Amber Smith: Do patients notice a difference right away?

Michael Costanza, MD: Well, if you have your aneurysm fixed with a stent versus the aneurysm fixed with an open procedure, it's a world of difference. You know, it's patients are walking the next day versus being in the ICU for the first four or five days. It's a huge difference in terms of this particular technology. I think the main thing is that we really don't have those prolonged X-ray exposures that we have to worry about skin breakdown or things like that, or having the kidneys be affected by the amount of contrast used. So that would all be taken out of the equation for those patients.

Host Amber Smith: Do you have any predictions about how this technology may evolve?

Michael Costanza, MD: Yeah, it's very exciting. I've seen some of the kind of research done with this particular device, and what they will envision is that this will become more like virtual reality. I think the surgeons will eventually put on the glasses, and the image will actually be projected right onto the patient, him or herself. And we'll just work off of that. Instead of working off a monitor, you'll just look straight down and see everything that you see on the X-rays, just see it on the patient, which will be really a very intuitive way to do these things. And we'll just speed the process and take us to the next level.

But I've already seen the prototypes for that, and it's really exciting what's coming up.

Host Amber Smith: Very encouraging. Well, thank you so much for making time to tell us about it, Dr. Costanza.

Michael Costanza, MD: It's a pleasure. Thanks for having me.

Host Amber Smith: My guest has been Upstate professor of surgery, Dr. Michael Costanza, who leads to the division of vascular surgery and endovascular services at Upstate. "The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at upstate.edu/informed. This is your host, Amber Smith, thanking you for listening.