Intraprocedural imaging: flat panel detectors, rotational angiography, FluoroCT, IVUS, or still the portable C-arm?

Fluoroscopy is the current standard by which intraoperative imaging is performed during endovascular aortic interventions. The goal of the imaging system is to provide adequate visualization of the aorta and its branches throughout the entire range of the treatment area. This may range from the femoral arteries through the ascending aorta. While the endovascular treatment of descending thoracic aortic aneurysm and abdominal aortic aneurysms (AAA) is becoming commonplace, the evolution of this specialty is toward providing less invasive approaches to increasingly complex disease processes. The imaging systems that allow us to perform these procedures through small incisions, or needle punctures, must evolve with the device technology to facilitate this growing complexity. In addition to providing adequate visualization of the aorta, its branches, and the tools that are used to place them, the technology needs to be safe, for both the patient and the operative team. The imaging system should allow the operator to perform complex procedures with limited use of radiation and contrast agents. Limiting radiation exposure is also important for the operative team, as radiation effects are cumulative and will become compounded over a career of fluoroscopy-directed procedures. While it is easy to stay up-to-date with the latest endovascular therapies that may be offered to our patients, as vascular surgeons it is often more difficult to keep apprised of the advancements in imaging technology that will allow us to provide therapies in a more efficient and safe fashion. This review will highlight some of the current advances in imaging that are available.