CT-Fluoroscopy Image-Fusion Guidance for Embolization of Aortopulmonary Collaterals

BACKGROUND: In adults with congenital heart disease, anatomically complex culprit collateral vessels may cause life-threatening hemoptysis and require catheter-based embolization. Techniques using conventional 2-dimensional (2D) fluoroscopy can be challenging. TECHNIQUE: We describe a technique using 2D/3-dimensional (3D) image fusion for intraprocedural guidance to embolize aortopulmonary collaterals. Two fluoroscopic images of the thorax at least 30° apart with pigtail catheter in the ascending aorta were used for image fusion with preprocedural computed tomography (CT) angiography using the spine and pigtail catheter as landmarks. 3D planning information was overlaid on 2D fluoroscopy for cannulation and embolization. RESULTS: Between November 2018 and June 2019, a total of 6 sessions of aortopulmonary collateral embolization using CT-fluoroscopy image-fusion guidance were conducted in 3 patients with adult congenital heart disease. In 3/6 sessions, the indication for embolization was hemoptysis. Common target vessels were left and right bronchial arteries (4 and 3 sessions, respectively). The spine and a pigtail catheter in the aorta were frequently used as landmarks for image fusion (67%). Particle embolization was used in 100% of cases. Mean procedure and fluoroscopy times were 3 hours, 23 minutes and 1 hour, 3 minutes, respectively. On average, 169 mL (350 mg iodine/mL) of contrast material was used in each session and total skin dose of radiation exposure was 1538 mGy. Successful collateral embolization was confirmed by postprocedure angiography that showed negligible or no flow through culprit collaterals. CONCLUSION: Use of CT-fluoroscopy image-fusion guidance can aid in embolization of aortopulmonary collaterals with complex anatomy in 3D space.