Since the first mobile C-arm for use in surgery was launched commercially in 1955 by C.H.F. Müller GmbH, a part of the German Philips Medical Systems organization, the technology has come a long way.

The global market is expected to reach $2.6 billion by 2018, according to a Global Industry Analysts Inc. report published last year. The main triggers of this demand are enhanced image resolution and radiation dose reduction due to flat panel detectors.

Additionally, hospitals are looking to become as efficient as possible while cutting costs. Vendors are listening to their customers and responding by delivering the requested solutions. They created a variety of new features to try to improve workflow and integrating the C-arms with other systems has become the latest trend.

Integral integration
“I think the integration of different machines in an operating system or maybe even in a hospital is at the current forefront of technological advancement,” says Jon Snyder, chief technology officer for GE Healthcare’s surgery business. “It becomes very interesting when you start looking at the other devices in an OR and you look for the integration of them to create value, which is greater than that of either device by itself.”

The company has taken what it calls its “first step” in integrating mobile Carms with other systems. At RSNA 2012 it unveiled its OEC 9900 Elite mobile C-arm mounted within the workstation of the Venue 40 tablet ultrasound, which is the first mobile C-arm integrated with an ultrasound.

“The logic was—we can see that there are two devices which are providing value in the surgery suite and they’re providing different kinds of information,” says Snyder. “But the question that we ask is—is there value in bringing those two devices into one?”

Since this is such a new concept, GE is still in the process of learning how useful integrating the two systems is, but they believe that it will bring a lot of benefits.

One of the main potential benefits is freeing up space in the operating room. Space is such an important commodity in an operating room and any opportunity to conserve it is welcomed.

By integrating the systems, it frees up floor space and also requires fewer cords on the floor, which allows staff to clean up and turnover the operating room much faster.

Fresenius Vascular Care in Louisiana purchased the system recently and they say this is a big plus. “With the space savings, everything is combined right there so you don’t have to hide another piece of equipment or try to fit another piece of equipment somewhere close to the table in a confined place. Everything is kind of hidden in the console itself so it’s nice,” says Scott Bonvillain, interventional radiologic technologist at the facility.

Other than combining C-arms with ultrasounds, GE has explored other systems to connect them with. For the same C-arm, the company offers a wireless service platform feature that lets clinicians wirelessly transfer data to their PACS.

GE also coupled it with a compact communication and visualization and equipment management system called NuBoom M2. “It’s a way to integrate some of the other devices in the OR into a package with the OEC Elite,” says Snyder.

Right now, GE is the pioneer with this concept, but other companies including Philips Healthcare and Siemens Healthcare say they are considering it. “As we go forward, certainly, we’re going to continue to look at different ways to increase the interoperability across the system,” says Eric Hudson, senior field marketing manager of mobile surgery at Philips. “It behooves us to take advantage of that whenever we can—I would look to more of that in the future.”

Going with the flow
Hospitals are always trying to improve their workflow and many new C-arms on the market have built-in features to do just that.

Motorization was originally only offered in fixed C-arms, but GE was the first company to bring it to mobile units. Ziehm Imaging claims that with its new Vision RFD Hybrid Edition mobile C-arm, it has taken things one step further.

It is the only mobile C-arm on the market that is full motorized in four axes—horizontal, vertical, orbital and rotational and in angulation.
Additionally, each position can be stored and then called up again at any time.


“It makes the workflow easier, that’s at least what we experience and hope it will be globally,” says Martin Herzmann, director of global marketing for Ziehm. Traditionally, a sterile surgeon has to tell an unsterile nurse the position to put the C-arm in, but with motorization in all four axes, the surgeon can control the system with a sterile touch screen and joystick that is mounted on the OR table.

The Ziehm C-arm is also equipped with a distance control system that prevents it from colliding with the patient or surgeon. There is a sensitive area around the lower edge of the FPD that detects the patient’s anatomy and assists the surgeon to stop the C-arm before it touches the patient or anything else in the vicinity.

“In order to ensure a maximum level of sterility it is important to keep a safety zone around the site free,” says Herzmann. “OR staff can totally focus on the patient and not on the technological set-up and controlling the arrangement of the equipment.”

Siemens’ Cios Alpha, which just received FDA clearance, also has motorization capabilities, but it uses single-touch positioning. When the surgeon presses a button, the Carm starts to move and it also has the option of storing position settings for quick call-up.

“If you take an image in a certain position of the C-arm, it will store that position so you can return to that same exact position to do a verification of that image as well as that region of interest with that single touch positioning,” says Parag Patel, product manager for mobile C-arms at Siemens.

Philip’s Veradius Neo also has built-in features to help improve workflow. The C-arm is color-coded so that there are clear visual aids as the system moves, which allows for easier communication between the surgeon and technician. It has a counterbalanced arm so that it won’t start to creep during a procedure and cause the surgeon to lose the position it was in. Also, the startup time has been decreased to just two minutes so if there is an urgent case, surgeons won’t have to wait long for the system to boot up.

FPD takeover?
It’s well-known that it has been a goal in the health care industry to reduce radiation dose while improving image quality for some time. Although C-arms don’t emit as much radiation as a CT, it’s still is a concern.

Fixed C-arms have historically been equipped with FPD and mobile C-arms were equipped with the less-advanced image intensifier technology. That changed when Ziehm introduced flat panel detectors to mobile units in 2006. Now, almost every new mobile unit on the market today uses this type of technology.

“Flat panel technology in the past was only available on fixed and ceiling mounted systems, but now it’s available on the mobile device, which means we can now compare the mobile C-arm image quality-wise to a fixed installed unit,” says Ziehm’s Herzmann.

Ziehm just recently released its new Vision RFD Hybrid Edition and Herzmann says that it can run the same clinical applications as fixed units including transcatheter aortic valve replacement.

Meanwhile, Philips showcased its latest mobile C-arm with FPD at RSNA back in 2011. The Veradius Neo uses a rotating anode along with constant beam filtration in its X-ray generator, which enables more penetration into the patient and minimizes or eliminates the amount of soft radiation.

When vendors are creating a new C-arm, there is a balance that needs to be struck between image quality and dose. “We need to make sure that we are striking that balance and trying to tip it more in the practitioners favor and the patients favor by providing the image quality we can at the lowest dose possible,” says Philips’ Hudson.

Siemens’ Cios Alpha, is also equipped with this technology but the difference is that it’s the only mobile C-arm that uses Full View FD technology. This new technology enables the collimators to track the image rotation in order to get 25 percent more image coverage.

It also has what Siemens calls the Retina Imaging Chain with Intelligent Dose Efficiency Algorithm dose reduction, which optimizes the dose and enhances the image quality. “It’s a new way of creating better image quality with the FD device, while keeping the doses low as possible,” says Siemens’ Patel.

Not so fast
FPDs have been proven to improve image quality and reduce radiation dose, but experts say they still haven’t been widely adopted because they are so expensive.

Based on an InMedica market forecast report from November 2012, image intensifiers for 2014 are estimated to cost in the range of $70,000 to $120,000 and FPD are estimated to range from $150,000 to $200,000.



“We’ve got a lot of hospitals that are largely happy with what they’ve got although they’ve realized some of the limitations that they have with the distortion and so forth,” says Hudson. Hospitals agree that FPD would be nice to have, but they are not going to go out of their way to get a new C-arm, he adds.

The goal to lower costs in a tight economic environment has also caused many hospitals to turn the other way.

“We know all the impact the Affordable Care Act is having on the industry—folks are looking more and more toward reducing the costs of health care and looking at total cost of ownership,” says Hudson. Philips is currently looking to find ways to get around the cost issue in order to get a “win-win for everybody involved.”

The way they are trying to make that happen is by positioning the C-arm as a multipurpose system, meaning that it can be used in a variety of different procedures from orthopedic to cardiovascular surgery. So the goal is to cover hospitals’ needs with a small fleet of 10 to 15 C-arms, depending on the size of the facility and its procedure volume.

Another reason that Philips believes the Neo offers efficiencies that outweigh the cost is the fact that it can accept video from an endoscope and ultrasound. Clinicians can see the X-ray image and ultrasound or endoscopic image side-by-side.

The InMedica report stated that the FPD mobile C-arm market is expect to grow 54 percent from 2011 to 2016. However, FPD will still remain a small portion of the whole mobile C-arm market since it’s more expensive than image intensifiers.

Sarah Jones, an InMedica analyst, reported that FPD units represented 9 percent of total unit shipments in 2011, which is still a small proportion.

When the first mobile C-arm was manufactured, it couldn’t compare with fixed installed units. But over 50 years later it has become a force to be reckoned with. “This is kind of the paradigm shift, which is currently happening,” says Ziehm’s Herzmann. “Traditionally, the bigger units have been the gold standard, but now this paradigm seems to be shifted onto the image quality counts, whether it’s mobile or fixed.”

Click here to check out the DOTmed New Equipment Guide for C-arms.

DOTmed Registered HCBN April 2014 C-arm Companies

Names in boldface are Premium Listings.
Domestic
Ted Huss, Medical Imaging Resources, CA
DOTmed Certified
Kristopher Derentz, Multi Imager Surgical, CA
Elie Semaan, Rayon-x Engineering, LLC, CA
DOTmed Certified
Ben Quick, Soma Technology, Inc., CT
Moshe Alkalay, Hi Tech Int'l Group, FL
DOTmed Certified
David Denholtz, Integrity Medical Systems, Inc., FL
DOTmed Certified
DOTmed 100
Larry Sprague, Imaging Resources, GA
Mark Conyers, Chicago C-Arms, LLC., IL
James Flanigan, FI Sales, LLC, IL
Mark Forcier, JD Honigberg International, IL
Davyn McGuire, Med Exchange International, Inc., MA
DOTmed Certified
Wayne Horsman, Columbia Imaging Inc, MD
Chris Sharrock, Block Imaging International, Inc., MI
DOTmed 100
Joe Zaremba, Advanco Medical Systems, MO
Brian Ross, Creative Kinetics, LLC, NV
Stuart Egles, Atlantis Worldwide LLC, NY
Kristen Ferris, Bay Shore Medical, NY
Matthew Blaustein, Bluestone Diagnostics, Inc., NY
DOTmed Certified
Robert Muzzio, GXC Imaging, NY
Leon Gugel, Metropolis International, NY
DOTmed Certified
DOTmed 100
Gordon Frye, Surgical Imaging Associates, LLC, NY
Patrick Doyle, Medical Exporters, Inc, TN
DOTmed Certified
Michael Baumgartner, Remesta Medical Corp., TN
DOTmed Certified
Robert Woodward, TransAmerican, UT
DOTmed 100
Frank Homa, Oakworks, PA
Jeff Weiss, Atlantis Worldwide, LLC, NY
Rodrigo Henao, Medilab Global, FL
Robert Iravani, Chicago MEDX, TransAmerican, IL
Kevin Blaser, Coast to Coast Medical, MA
Troy Joncas, Surgical Tables, MA
Steve Walsh, Eastern Diagnostic Imaging, Inc., MA
John Lee, Comed Medical Systems Co., Ltd., MI
John Pereira, United Medical Technologies, FL
DOTmed Certified
Robert Serros, Amber Diagnostics, FL
DOTmed 100
Tony Orlando, Complete Medical Services, MI
DOTmed Certified
DOTmed 100
Robert Manetta, Nationwide Imaging Services, NJ
DOTmed Certified
DOTmed 100
Ted Huss, Medical Imaging Resources, CA
DOTmed Certified
John Kolleger, Bayshore Medical Equipment, Inc., NY
DOTmed Certified
DOTmed 100
Tony Smith, Classic Diagnostic Imaging, OH
DOTmed Certified
Ken Saltrick, Engineering Services, OH
DOTmed Certified

International
David Lapenat, ANDA Medical, Canada
DOTmed Certified
Moshe Alkalay, Hi Tech Int'l Group, FL
DOTmed Certified
Welshen Gao, Doododo Medical, China
DOTmed 100
Mads Vittrup, AGITO Medical, Denmark
DOTmed Certified
DOTmed 100
Martin Herzmann, Ziehm Imaging, Germany
Arthur Singh, ARTHUR MEDI COMP TRONICS, India
Rick Meerkerk, Mediproma B.V., Netherlands
DOTmed Certified
DOTmed 100