The Siemens Nexaris Angio-CT combines angiography with computed tomography systems in one environment for interventional procedures. IO Learning spoke with David Lacey, MD, an Interventional Radiologist at Iowa Methodist Medical Center. Dr Lacey was one of the first in the United States to utilize the first-generation Angio-CT technology and was instrumental in the development for the current generation, Nexaris.
Tell us about your initial experience with Siemen’s Nexaris. Has that experience changed over time?
Our institution installed our Angio-CT unit in 2013, so we’ve had it for 7 years now. In one sense, it was the shiny new machine that featured the latest technology, but in another sense, it was very comfortable and easy to use, because it comprised two systems we were already very familiar with — angiography and CT. First and foremost, the unit added confidence to our cases, in that it lowered the threshold to obtain cross-sectional imaging. It also improved our workflows. Today, many interventionists use cone-beam CT, much like I did previously. However, Angio-CT has almost completely replaced cone-beam CT in our workflow. My opinion on the Angio-CT really hasn’t changed over the last 7 years. I am just as impressed with Angio-CT today as the day it was installed at Iowa Methodist.
Do you have any thoughts on the upgraded features with Nexaris in comparison with the workflow on Miyabi?
I think physicians typically have very short attention spans and are pretty “type A.” One of the biggest impediments to using new technology is operational complexity. Miyabi is the original version of the Angio-CT unit, combining the two systems in the same room. This was amazing, but it was somewhat complex to use. We recently upgraded to the newer-generation Nexaris, and this has significantly improved our workflow. For example, switching between CT and angio is even easier with the Nexaris quick-switch functionality. Quick-switching has essentially removed the hesitation to use CT from the equation; my use of CT has increased, because it requires very little effort. Essentially, we can have both systems ready to go and slide the patient back and forth between the two very quickly.
Another upgrade with Nexaris is Instant Fusion, which allows immediate overlay of 3D imaging and objects onto fluoroscopy. This workflow is now much more streamlined. This was possible with the Miyabi version, but it entailed a lot of button clicks, and physicians do not like to do a lot of steps. The Nexaris upgrades make all workflow automatic. The 3D overlay feature is particularly helpful while doing liver interventions, such as Y-90 or chemoembolization, where we need to navigate to a small vessel target.
The Nexaris also co-registers the patient demographics on both systems; if you register a patient on the angio system, the CT is already keyed up and ready to go. One might think this is an insignificant feature, but it means the technologist does not have to stop working and do a lot of keyboarding to prepare the CT scanner. The CT is right there and ready to go, and again, this ease of use has lowered the threshold to use the combined modalities. The streamlined and automatic workflows with the Nexaris upgrade make using this system a joy.
Do you believe Angio-CT affects patient outcomes?
I believe the Angio-CT unit positively affects outcomes, and also allows me to undertake more difficult cases. In the past, I may have been reluctant to perform certain complex cases, but now I have cross-sectional imaging readily available to help address any procedural or clinical issues. I can definitely say that this system has bailed out many complicated procedures, and I have had better outcomes because of this technology. My biggest problem is that my partners and I fight over this system because we all think our cases are the most challenging, so my only complaint is that I have to share the Angio-CT unit with my partners.
Does your entire practice prefer to use the Nexaris unit over your other angiography systems?
Yes. When we add new technology like Nexaris, it can be challenging to encourage adoption among my partners. Sometimes more experienced users are hesitant to adopt new technology. This hasn’t been the case with Angio-CT — all of my partners used it almost immediately. With the Nexaris, there is the comfort of familiarity. We all know how to use a CT and fluoroscopy by themselves; having both of our favorite tools in the same location made it no contest for the favorite angio system in the department.
Most of the Angio-CT customers in the United States have been from large academic institutions. Are there underlying causes driving this trend? How do you see the role for Angio-CT in community hospitals evolving in the future?
I am one of the early users, but I am not at an academic institution, so I am an outlier. Academic centers typically adopt new technology and prove that it is effective. Therefore, it is not surprising that they have been the early customers for this technology. However, I think there is another reason the Angio-CT has been so readily adopted at academic centers. Very commonly, CT is not available in an academic IR department, because it is usually located within the “body” Radiology division. Therefore, to utilize a CT scanner across the hospital in combination with angiography at an academic institution might be difficult from an operational point of view. The Angio-CT effectively adds a CT scanner directly to the IR department. While a hospital might not allocate funds to buy a stand-alone CT for IR, the purchase of a hybrid Angio-CT might provide a workaround to institutional politics, bringing a new service line to the IR department. In addition, there is a tremendous amount of use for this system beyond the usual diagnostic needs, so I can understand why many academic centers have purchased the Angio-CT.
On the non-academic side, I think private practices that don’t have the Angio-CT are missing an opportunity. I believe it is only a matter of time before other private practices integrate the Angio-CT. Interventional radiology cases have evolved over time to include more cancer therapy, and many of these therapies require cross-sectional imaging. Our private practice has a tremendous need for the Angio-CT for our oncology work, which ranges from simple biopsies all the way to ablations and liver-directed therapy. Another thing that I believe will drive the adoption of Angio-CT is that the current generation of IR residents will train on this technology and become accustomed to its benefits, and will expect it to be available as they move into the world of private practice. Angio-CT will soon be considered the standard of care as practices and clinical needs evolve.
You mentioned the evolving clinical needs and procedure mix in IR. Is there a potential opportunity for Nexaris to support those cases in the long term?
Interventional radiology is a rapidly expanding, dynamic field. Cross-sectional imaging has proven to be beneficial for nearly all IR procedures. For example, there has been a lot of recent interest in prostate artery embolization (PAE); if PAE really takes off, Angio-CT would be an excellent resource for these complex procedures. Because IR is gravitating toward oncology techniques and other procedures that benefit from cross-sectional imaging, Angio-CT will be imperative as these therapies evolve.
How has the addition of Nexaris affected your department’s workflow and operational efficiency?
The Angio-CT is what I like to call our “yes” room. Absolutely anything that I do as an IR physician can be done in this room. I can do CT in this room. I can do fluoroscopy. I can do ultrasound. It covers the entire spectrum of procedures I might do as an IR, which is really useful from a workflow point of view. The biggest limitation in most hospitals is floor space. Unless we are rebuilding a department from scratch (which is incredibly expensive), most of us are trying to cram more things inside a fixed area. Interventional radiology business is growing. We are constantly trying to figure out how to get more done within our existing walls. The beauty of Angio-CT is that since it allows me to perform any procedure, it becomes the most operationally efficient room in our department. It is not a one-trick pony. Nexaris is an extraordinarily useful tool that streamlines our workflow.
We are also able to operate the Angio-CT with our existing angio techs. We don’t need a CT tech one day and an angio tech another day; we have one set of staff that has been trained to run everything. Because this does not need a special crew, staff are always available to do whatever is needed. Therefore, from an efficiency point of view, the Angio-CT room is our best producer in the department.
How are you performing procedures differently with the Angio-CT?
A large number of my procedures begin with a percutaneous needle stick. In the past, I have used the usual ultrasound and fluoroscopic guidance. The Nexaris brings the excellent Siemens Adaptive 3D Intervention software to the mix and this has been a fantastic tool. I have found that this is usually the safest, most accurate, and fastest way to place a needle. For example, I no longer dread decompressed nephrostomy tube placement. I give the patient a small amount of contrast and target the calyx with the 3D CT guidance tools. Once the needle is in, we can immediately switch to fluoroscopy.
Another challenge IRs often face is keeping our patients comfortable, but alert enough to hold their breath during interventional procedures. In the past, we were challenged with coaching patients through the long breathholds required for cone-beam CT. The real benefit of the Nexaris is that even if the patient cannot hold their breath, the resulting images will be usable. My personal success rate with cone-beam CT was around 60% usable scans. With the Nexaris, it is nearly 100% success.
How did you get buy-in from your institution’s administration for the purchase of the Angio-CT, and what advice would you give to other institutions?
Our IR business was growing and we persuaded administration to purchase our Angio-CT unit based on the merits of the operational efficiency it had opportunity to provide. We did not have the floor space for another CT scanner and another standalone angio unit. The addition of the Angio-CT to our hospital allowed us to put both systems within the same floor space and to run them with the same set of staff. We were able to sell our administration on the concept of a room that would run at very high efficiency and offer the flexibility of a hybrid system. While there are added costs associated with Angio-CT, at the end of the day, my unit produces profit due to its high utilization.
You mentioned the up-front investment — would you say that it was a wise investment?
Absolutely. We paid for the Angio-CT unit within 9 months of our purchase based on the new revenue that we generated in our growing business. Our system is highly utilized and brought in a lot of gains even in its first year. Therefore, the financial gains past that break-even point are doing quite well. Again, if we look at the growth of IR beyond the conventional cases, we are performing a large number of cancer-related cases, such as biopsies, which lead to other downstream work. The bottom line is that the Angio-CT is a flex unit, which has resulted in an excellent return on investment. It is our best-performing angio system from an economic standpoint.
Is the economic benefit entirely due to increased case volume?
We bill for CT angiography codes in a lot of our procedures; it is preauthorized and we get paid for it. However, that is not where the institution sees a profit from the system. Again, when I am explaining the benefits of purchasing a new unit to a hospital administrator, the system has to be something I use every day on multiple occasions. Different-sized institutions would see variable benefits. At a larger institution that already has many CT scanners, the Angio-CT might not move the needle tremendously in terms of revenue, but a machine that can flex to one modality or the other at a small or mid-sized institution makes a huge impact on the types of cases that can be done each day. A smaller hospital might even use Angio-CT for diagnostic imaging a lot of the time, and only occasionally perform interventional cases with it. As I mentioned, when we think of the initial equipment costs, we have to remember that construction in a hospital is tremendously expensive, and adding another room to house a new piece of equipment is often cost prohibitive. The Angio-CT maximizes the value of the current square footage and the full-time employees that are tied to it, so they are always making money. That is the most compelling reason to purchase the Angio-CT from a business standpoint.
Do you have any final thoughts on what the future holds regarding integrated imaging?
Based on my experience, I believe this will become the standard of care. Would I start over and go to a new hospital without an Angio-CT? The answer is no, I definitely want one. Granted, it is not necessary for every case, but the fact that it is available when you need it really makes a difference in clinical practice; it makes a difference in my confidence and efficiency, and I guarantee it makes an impact on my patients’ outcomes. In the future, I believe every IR department will have at least one Angio-CT, and, in fact, as we look at future equipment purchases, we would love to have more than one Angio-CT at Iowa Methodist Medical Center. For some reason, this technology has flown under the radar here in the United States, but I believe that as it becomes more well known and adopted, every IR will want one.
The statements by Siemens’ customers described herein are based on results that were achieved in the customer’s unique setting. Since there is no “typical” setting and many variables exist there can be no guarantee that other customers will achieve the same results.
Disclosure: Dr Lacey has completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. He reports personal fees from Siemens Healthineers.
Address for Correspondence: David Lacey, MD, Iowa Methodist Medical Center, 1221 Pleasant Street, Des Moines, IA 50309.