C-arm imaging is a medical imaging technique that uses X-rays to produce real-time images of an individual’s internal structures. C-arms are used in a variety of procedures, including orthopedic procedures, cardiac and angiography studies, therapeutic studies, pain management, emergency procedures, urology and gastroenterology.
ICE Magazine Editor John Wallace reached out to several healthcare systems seeking input from subject matter experts on C-arms for this Director’s Circle article. Participants are:
• Ashley Adams, MHI, BSRT(R)(VI), perioperative and procedural imaging manager, The Ohio State Wexner Medical Center
• Tosca Bridges, M.S., R.T.(R)(CT)(QM), director radiology clinical operations adult services (interim), The University of California San Francisco
• Jill Jones, associate director of medical imaging, Banner Imaging outpatient clinics in Arizona
• Edward Richards, radiology supervisor for surgery, University Hospitals of Cleveland.
Q: What key factors influenced your decision to select your current C-arm models?
Adams: We take an approach that ensures we have a balance of performance, usability and ongoing support by focusing on three key factors.
• Image Quality and Functionality: Ensuring the equipment delivers high-resolution images and meets the functional requirements for a wide range of procedures is a top priority.
• Ease of Use: It’s essential that the equipment is user-friendly, allowing radiology technologists to operate it efficiently and confidently.
• Service Agreement and Training: A comprehensive service agreement is critical to addressing any equipment issues promptly. Additionally, the training provided by the vendor as part of the purchase is a significant factor, as it ensures the team is well-prepared to use the equipment effectively.
Bridges: There are several key factors that influenced UCSF Medical Center’s decision to select the GE OEC Elite CFD model as our standardized fleet imaging instrument.
The quality of imaging was the most important consideration in selecting the GE OEC CFD. The mobile viewing station for the GE consisted of a monitor-view-station (MVS) equipped with a 4K (3840 X 2160) or 8,294,400-pixel resolution monitor. With a dynamic large FOV CMOS field detector (31×31 cm or 21×21 cm), the 1548 x 1524 pixels is able produce the highest quality images for trauma orthopedics, neuro spine, urology, and vascular imaging, just to name a few services.
A second consideration was the large arc depth of the “C” (33-inch depth) on the C-arm which allowed for uninhibited RAO/LAO or CRA/CAU movements to image the patient anatomy. The arc depth was a strong consideration also because many cases use arm boards for radial/brachial IV access or the arms are placed in “superman” pose as to not superimpose the arms in the field-of-view. Having the large arc depth allowed for unfettered angulation of the C-arm on larger habitus patients, patients with difficult anatomy or pathology, or suites with room constraints on the anesthesia cart placement.
A third consideration was the X-ray tube configuration of the GE system versus the other three vendors. The GE OEC CFD has a split-block configuration where the generator is housed in the “C” separated by a high-voltage cable. A mono-block configuration houses the key components (X-ray tube anode, generator, and cable) in one tube housing. The difference is a split block has a smaller footprint, greater flexibility and ROM for positioning, and dissipates heat faster with active cooling. The Siemens Cios Alpha C-Arm does a split-block configuration like the GE OEC CFD, however, the system footprint and IQ played a determining factor in our decision.
A fourth consideration, that may get overlooked in many purchasing decisions, is service for work orders and repair. At UCSF, we have purchased Philips, Ziehm, Siemens, and GE C-arms in the past five years and have had a chance to observe service call response and repair turnaround times. In our observation, we noticed better service and parts availability for repairs with GE C-arm systems compared to its competition. This can be due to more available local field-service-engineers or a parts depot in closer proximity. However, this consideration did play a significant role in our decision-making process on which vendor was the correct choice in an effort to standardize our fleet enterprise-wide.
A fifth consideration was the unit cost of each system and preferred discounts the vendor would provide to our large institution for a bulk purchase. UCSF did include other UC sites in our decision-making process, including UC Davis. This transparency and inclusion helped other sites decide on which product was also best for them and negotiate bulk purchases across the UC enterprise.
A sixth consideration was patient radiation dose and while this was hard to assess we did notice this was directly related to imaging quality (IQ) and available algorithms. GE had many options on its touch-user-interface that allowed us to reduce dose while maintaining IQ. This was more present during the actual on-site demos which allowed us to get feedback from surgeons in real-time on what was acceptable vs. ideal.
Jones: Currently we have several GE C-arms. We purchased these due to the familiarity of the technologist with the equipment as most had worked on these types of units in the past. We did just recently purchase a Siemens C-arm. We purchased this due to the size of the unit for a more compact area as well as using several other Siemens products.
Richards: We went with GE OEC because they are very dependable and tech friendly. The C-arms we replaced were anywhere from 15 to 20 years old.
Q: What challenges did you face during the procurement process?
Adams: One of the primary challenges during the procurement process was coordinating the equipment delivery timeline to align with the approvals required from clinical engineering and radiation physics, ensuring a smooth and efficient implementation.
Bridges: During the procurement process we faced a host of challenges as we conducted an open-source vendor fair during COVID pandemic in 2020. During this timeframe, many projects at UCSF Medical Center were either delayed due to budgetary constraints or discontinued due to pandemic-related limitations. We formed a UCSF C-Arm Purchasing Committee in the summer of 2020 to include key stakeholders for their input and assessment of the vendors. Key stakeholders included radiology technologists, radiology leaders from multiple UCSF sites, surgeons from different disciplines, clinical technologies imaging (biomed), and our UCSF procurement team. Forming this team was time-consuming as much coordination was needed to include parties from different shifts and various UCSF medical sites. Upon formation of this committee, we had to dedicate time, in-between patient care and multiple other projects, to conduct research on each vendor to present a transparent comparison at each vendors product. We hosted four vendors (GE, Philips, Ziehm, and Siemens) in a virtual vendor fair (Aug./Sept. 2020) which required a presentation of product information to all our stakeholders via zoom. Due to the pandemic, we could not host each vendor for on-site demos which may have limited our assessment of the capabilities of each C-arm. However, the UCSF C-Arm Purchasing Committee compiled a C-arm specification fact sheet and a vendor comparison PowerPoint for all stakeholders, pre-vendor virtual presentations, to make the process as transparent as possible. Post vendor presentations, we utilized Survey Monkey for an anonymous vote by our stakeholders to select two vendors for on-site demos. Upon that selection, we hosted two vendors in Oct./Nov. 2020, dedicating one week each, within our Parnassus OR. After the demos, we selected one vendor in Dec. 2020 to move forward as our standardized C-arm fleet vendor. This was a time-consuming process requiring coordination with our vendors, stakeholders, procurement team, and periop team. We utilized the demo to validate claims made by the vendors and to assess each system in a multitude of cases with different services.
Jones: We did not face any major issues during our procurement process. We went through the standard purchasing process to obtain PO and funds and then purchase our units.
Richards: There are many different challenges because we replaced all our C-arms, 14 in all within a two-month period. This ranged from getting approval from upper management, figuring out the different models that we needed, to coordinating delivery of three or four C-arms every couple of weeks.
Q: What strategies have you implemented to maximize C-arm utilization?
Adams: To maximize C-arm utilization, we have implemented a targeted staffing model designed to align with the specific environments in which the C-arms are utilized. We also focus on resource stewardship by ensuring active utilization of equipment and systematically replacing underused units to enhance operational efficiency and optimize resource allocation.
Bridges: To maximize C-arm utilization within our OR we have set up several workflows. First, we work with our periop equipment utilization team to ensure that correct amount and type of C-arm is available for booking. We currently have 13 C-arms in our Parnassus OR which gives surgeons the ability to book their cases in the OR without fear of not having an instrument for imaging. Although our C-arms are the same model, we purchased different configurations to help best serve several different services. Our C-arm fleet consists of a motorized GE OEC CFD vascular C-arm, GE OEC CFD super “C” 21 cm flat detector, GE OEC CFD super “C” 31 cm flat detector, Philips Veradius Unity, and Ziehm 3D RFD Vision. Second, we work with our periop charge nurses, POD managers, and periop triad to communicate any down equipment with approximate repair turnaround times. This helps utilize other C-arms, move start times for cases to ensure imaging instruments are available, or find alternatives in imaging to ensure cases can be performed. Our current fleet of C-arms is predominantly GE; however, we still utilize Philips Veradius Unity and Ziehm 3D RFD models within our fleet for specialized spine cases, urology, and/or bronchoscopy navigation cases. Third, we work with other radiology modalities to help perform cases that require multiple forms of imaging. An example would be in CT where we perform Kyphoplasty cases that require the CT scanner and a mobile C-arm. Utilizing our C-arms for these procedures ensures we maximize utilization of our instruments and best serve our patients.
Jones: To maximize our C-arm use at our facilities, we must work closely with the radiologist and radiologist assistant to cover all of our facilities that offer C-arm procedures. On the days that we schedule procedures, we maximize the use of the physicians and assistants to get as many done as possible in our workday.
Richards: Every morning, we look at the schedule for that day to determine which cases will need the larger unit. Like, for instance, if we have a pelvic osteotomy, humerus rodding or other complicated case they will get the large C-arm and the smaller ones will be for simpler cases.
Q: Are there any upcoming trends in C-arm technology that excite you?
Adams: The advancements in 3D C-arm technology are really exciting, especially when you think about how they can be applied across different surgical specialties. The ability to provide real-time, high-resolution 3D imaging makes a huge difference in improving precision and outcomes for a variety of complex procedures.
Bridges: C-arm technology or trends that are potentially exciting include the improvement of 3D C-arm systems that allow for 3D spine and multiplanar reconstructions. UCSF Medical Center is a research facility and a teaching hospital; therefore, we perform many different types of cases utilizing navigation platforms (spine navigation using Brain Lab or Medtronic Stealth, and Bronchoscopy Ion). When using navigation platforms for precise instrumentation placement and/or revisions, the imaging software required to confirm placement of screws or needles is very important. The imaging technology of 3D systems allows us to image anatomy and hardware in multiple planes with low dose. This helps in the accuracy of hardware placement and increases patient care outcomes. Although 3D C-arm technology is still in its infancy regarding software and integration, the technology could prove to help create better workflows at a lower cost than traditional imaging methods such as the Medtronic O-Arm.
Jones: Some upcoming trends in C-Arm technology are:
• Better imaging: Manufacturers are developing flat-panel detectors with higher resolution and contrast for clearer X-ray images.
• AI and machine learning: These technologies can help with image processing, reduce noise, and identify anatomical structures.
• Robotics: Robotic arms can help position C-arms more precisely, which can improve workflow and reduce strain on operators.
• More compact and maneuverable mobile C-arms: These C-arms can be used in tight spaces or during complex procedures.
• 3D imaging: This can improve procedure planning, intraoperative guidance, and reduce procedure time.
• Advanced software: Modern systems include software to assist with image processing and data management.
• Intuitive user interfaces: These interfaces can improve workflow efficiency and ease of use.
Richards: Last year, we also demoed a GE 3D C-arm for some ortho cases and it was amazing how clear the images had come out and the surgeons were very happy with the quality of the images too. I think this will be the trend of the future.
Q: What are the biggest challenges you face regarding C-arms in your facility?
Adams: One of the biggest challenges we face is the limited storage capacity for C-arm equipment, as well as securing dedicated space for performing routine preventive maintenance.
Bridges: The biggest challenges UCSF Medical Center faces regarding our C-arms is multifaceted and at times out of our control. First, like any large teaching/research facility, we face challenges of productivity and availability. For us to be productive as an institution our instruments need to be available for casework. It is not uncommon for our equipment to be down for several weeks as we wait on parts and/or service. This is probably due to the staffing of vendors and supply-chain-management issues regarding foreign-produced parts. Second, we face the challenge of making sure the user and end-user of the equipment is properly trained and proficient in understanding the proper utilization of instrument. This requires training and re-training of staff. Having poorly trained staff can cause harm to patients, improper use the of equipment, damage to the equipment and poor surgical procedure outcomes. Third, a challenge that most facilities don’t consider is proper storage space for its inventory of C-arms. I imagine many facilities face issues regarding how to store equipment when not in use or when it needs to be serviced. UCSF does not have a large reservoir of space to park our fleet of C-arms. Therefore, we are in constant motion moving equipment around from OR suites back to a designated storage area with an accessible outlet for charging. Because C-arms consist of two large pieces, finding storage for 13 pieces of equipment is quite a challenge.
Jones: One of the biggest challenges with C-arm use in our outpatient facilities, is the radiologist or radiologist assistant coverage. Shortages in this field limit the number of days and procedures that we can offer our patients.
Richards: All the C-arms are wireless, which is great but sometimes there are areas in the OR where you can’t send your images. We just have to move them around until we get a signal.
Q: Are there any innovative uses or protocols you’ve implemented that others might benefit from?
Adams: We have implemented a quality check application that replaces paper-based processes, allowing radiology technologists to complete checks electronically and on-the-go. This innovation ensures that quality checks are performed consistently and efficiently daily, enhancing workflow.
Bridges: Some innovative uses or protocols that we have implemented is working with our navigation vendors for bronchoscopy to install software on our C-arms. This software is designed to make navigation for lung nodules much easier and more precise during a procedure. Another interesting innovation recently with C-arms has been the standardization of a small touchscreen user interface on the C-arm. Our radiologic technologists utilize this innovation to precisely position our equipment for specific anatomical imaging, to help measure vessels, and to mark areas proximal and distal for stenting or hardware pinning.
Jones: We are currently using our C-arms in the outpatient facilities for joint aspirations and injections and MRI and CT Arthrogram injections.
Richards: Currently, we are using the ROSA robot in conjunction with our C-arms for spine cases. The patients need to get a pre-op CT scan protocol that was put together with the surgeons, CT and the vendors which calls for 1mm cuts or smaller so that it can be used with the C-arm images and then converted over to the robot.
