Artis zeego

Surgical procedures were conducted in the Guided Therapeutics (GTx) operating room, which integrates an Artis Zeego (Siemens Healthcare) system for intraoperative CBCT imaging^{13 (link),22 (link)} (Fig. 1). This system is based on a flat-panel detector (1,920 × 2,480) and x-ray source (up to 125 kV) mounted on a robotic C-arm gantry. CT acquisition consisted of 248 x-ray projections obtained during a 10-second orbit, yielding images encompassing 25 × 25 × 18 cm using 0.5-mm³ voxels.
The custom navigation software (GTx-Eyes) provides different 3D visualizations, including triplanar views, bone-surface renderings, and clipping planes²³ . It also provides real-time feedback on the location and trajectory of planar cutting instruments in 2D and 3D views (Fig. 2). This has been validated in preclinical orthopaedic oncology studies in pelvic and extremity models^{24 (link),25 (link)} and in head and neck surgery^{26 ,27 (link)}. Various cutting instruments can be navigated using an intraoperative calibration jig (see Appendix Supplemental Figure 1).

Regarding the production of BNT (Figure 1), three-column ¹²⁵I seeds were regularly placed on a sticky medical device with a 5 mm interval distance, which was adhered to NFNT. The position was consistent with the occlusion according to pre-operative CT and esophagography results; ¹²⁵I seeds exceeded the tumor length by 2 cm above and below the tumor. Finally, No. 7 non-absorbable nylon wire was used to fix ¹²⁵I seeds to prevent displacement. Every ¹²⁵I radioactive seed (Tianjin Saide Biopharmaceutical Co., Ltd., China) was 4.5 mm × 0.8 mm, with an average energy of 27-35 keV, half-life of 59.6 days, tissue penetration capacity of 1.7 cm, and single seed radioactivity of 0.8 mCi. Fluoroscopy was performed with a flat-panel detector and digital subtraction angiography (Artis Zeego, Siemens, Germany).

Each patient underwent initial CBCT imaging for procedural planning and guidance using a robotic c-arm system and iPilot software (Artis zeego, Siemens Healthineers). No additional electromagnetic navigation or shape-sensing system was used. All CBCT imaging was performed using an 8-second protocol (396 projection images acquired at 0.5 deg/projection) during an inspiratory breath hold at Vt, using a ventilation protocol as described further.
In each patient, the target lesion was highlighted using a process called segmentation, on the initial CBCT scan, for overlay on live fluoroscopic images. Subsequently, CBCT augmented fluoroscopy (AF) was used to navigate a steerable catheter (Edge Firm Tip, Medtronic, varying degrees) to the target lesion. Once the navigation catheter was optimally aligned, a biopsy tool was inserted and advanced to the lesion. r-EBUS was used in all cases; these images were classified as concentric, eccentric, or none. Then, CBCT was performed again, for tool-in-lesion confirmation to assess if the biopsy tool was visible within the lesion in 3 orthogonal planes (axial, sagittal, and coronal). If the tool touched the lesion but was not inside the lesion, this was considered tool-touch-lesion (TTL). It was considered a center strike if the tool was in the middle third of the lesion in all views. Rapid onsite pathologic evaluation was utilized in all cases.

A floor-mounted multi-axis robotic C-arm monoplane DSA system (Artis zeego, Siemens Healthcare, Forchheim, Germany) equipped with “syngo X workplace” software (Siemens Healthcare, Forchheim, Germany) was employed in all cases. The system and software consist of a 3-dimensional rotational angiograph (3DRA), syngo DynaCT, syngo 3D stenosis measurement, syngo Aneurysm Guidance Neuro and syngo Needle Guidance software (syngo X workplace, Siemens Healthcare, Forchheim, Germany). The hybrid OR was also installed with a radiation-transmitting surgical table (MAGNUS OR Table System, Maquet GmbH, Rastatt, Germany), which allows for head flexion/extension, tilting to the right and left and Trendelenburg positions. We also have a radiolucent skull clamp and horseshoe headrest (Doro Radiolucent Headrest System, Pro Med Instruments, GmbH, Germany). This table and the instrument enable 3DRA and 3D CT in various patient positions. This system allows simultaneous endovascular and surgical treatment without moving the patient to another location or table. During cranial surgery, the multi-axis robotic C-arm is folded and placed so that it does not interfere with the microscope or other movement lines (Fig. 1).