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VesselIQ Xpress / AVA Xpress User Guide

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2007 General Electric Company inc. All rights reserved. User Guide

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Standards and Regulations

This product complies with the regulatory requirements of the following: - Council Directive 93/42/EEC concerning medical devices: the 0459 label affixed to the product testifies compliance to the Directive. For a system, the location of the CE marking label is described in the system manual. European registered place of business: GE Medical Systems SCS Quality Assurance Manager BP 34 F-78533 BUC CEDEX France Tel: +33 1 30 70 40 40 - Medical Device Good Manufacturing Practice Manual issued by the FDA (Food and Drug Administration, Department of Health, USA). - Underwriters Laboratories, Inc. (UL), an independent testing laboratory. - Canadian Standards Association (CSA). - International Electrotechnical Commission (IEC), international standards organization, when applicable. - USA/HHS: United States Federal law restricts this device to use by or on the order of a physician. - GE Medical Systems SCS is ISO 9001 and ISO 13485 certified. - The original document is written in English.

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Table of Contents
Standards and Regulations .........................................................................................................................2 Introduction.........................................................................................................................................................4 Product Description.........................................................................................................................................4 Safety......................................................................................................................................................................7
Intended Use......................................................................................................................................................................... 8 SOFTWARE SAFETY-RELATED MESSAGES ...............................................................................................................15 Feature List ............................................................................................................................................................................ 5

Image Requirements ................................................................................................................................... 16 Volume Viewer Tips ...................................................................................................................................... 17 VesselIQ Xpress Protocols ......................................................................................................................... 18 Launching VesselIQ Xpress....................................................................................................................... 21 VesselIQ Xpress Workflow......................................................................................................................... 23
Vessel Tracking ..................................................................................................................................................................23 Vessels to Analyze ............................................................................................................................................................23 Points Deposition ..............................................................................................................................................................24 Protocol Configuration ...................................................................................................................................................24 Centerline actions.............................................................................................................................................................25 Edit...........................................................................................................................................................................................25 AVA Preferences ................................................................................................................................................................26 AVA Tools: Edit/Measure ................................................................................................................................................27 Wizard Panel .......................................................................................................................................................................27 Edit trace/ Edit section....................................................................................................................................................28 Predefined Measurements............................................................................................................................................29 Manual Measurements ..................................................................................................................................................30 Types of Measurements.................................................................................................................................................31 Modify measurements....................................................................................................................................................31 Configuring Measurement Points and Related Measurements...................................................................32 Configuring Measurement Points..............................................................................................................................33 Configuring Related Measurements.........................................................................................................................33 Report.....................................................................................................................................................................................35 Saving and filming............................................................................................................................................................35

VesselIQ Xpress Layouts ............................................................................................................................ 37 Quick AVA .......................................................................................................................................................... 39 Interactive Thrombus Extraction............................................................................................................ 41 Side By Side Comparison Mode .............................................................................................................. 43 To use Side By Side comparison:............................................................................................................ 43 Color Identification........................................................................................................................................ 44 Stenosis and Aneurysm Tools.................................................................................................................. 45 Views And Controls....................................................................................................................................... 47 Measurements ................................................................................................................................................ 50 Glossary of Features .................................................................................................................................... 53
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Introduction
As with any medical imaging process, only qualified personnel should use this equipment. You must be aware of the limitations of the basic imaging modality and of ensuing image processing. This includes understanding the limitations of the initial series acquisition, imageprocessing technology used, and image display methods. This User Guide is a training material available on line on the workstation. Users need to review operating procedures on a regular basis, paying special attention to the Safety and Regulatory statements. Keep this User Guide available while using VesselIQ Xpress. This guide is sectioned into individual chapters to describe the workflow and provide instructions for the use of the features in VesselIQ Xpress. There is no correct order in which you should use these protocols. If you want to benefit from additional training, please contact your GE Healthcare User Services representative for assistance.

Product Description

VesselIQ Xpress is intended to provide an optimized non-invasive application to analyze vascular anatomy and pathology and aid in determining treatment paths from a set of Computed Tomography (CT) Angiographic images. VesselIQ Xpress is a post processing application option for the Volume Share (AW) platform, CT Scanner or PACS Stations. It can be used in the analysis of 2D and 3D CT Angiography images/data derived from DICOM 3.0 compliant CT scans for the purpose of cardiovascular and vascular disease assessment. One of the advantages of CT is that it shows both vascular and non-vascular anatomy. In addition, CT may be more useful for patients with limited or no peripheral access, with stents, or who may not be candidates for MRA. VesselIQ Xpress automatic visualization tools and features are designed to support the physician in the assessment of vascular structures. Once vessels are visualized, tools are available for sizing the vessel, analyzing calcified and non-calcified plaque to determine the densities of plaque within an artery, measure areas of abnormalities within a vessel, pre/post stent planning, and directional vessel tortuosity.

GE Healthcare Feature List

Features Basic Reformat Save State Five Layouts for improved workflow Customizable Layouts Single/Dual Quick AVA Multiple start points Auto-Tracking for select protocols New Anatomy focused protocols AutoBone for head and neck Autobone Abdomen /Chest and Lower limbs Integrated AutoBone Semi-Automated Thrombus Segmentation Compare Side-by-Side mode Pre-Defined Vessel Name list New Stenosis & Aneurysm tools Color Identification Reporting AVA Xpress X X X X X X X VesselIQ Xpress X X X X X X X X X X X X X X X X X

X X X

System Requirements
DICOM image data sets Volume Share 2.0 and higher Volume Viewer 3 and higher

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Safety

To assure an efficient and safe use of VesselIQ Xpress, it is essential to read this chapter before attempting to use the package. This chapter is extremely important. It contains safety information that you must thoroughly understand before you begin to use the software. The users of VesselIQ Xpress software application shall be a CT, MR, nuclear medicine, or radiology technologist, radiologist, cardiologist, or physician qualified with advanced applications training for software competencies or other personnel that the owner feels is properly trained for this software use (radiology assistant, physician assistant, etc.). To avoid usability error, the user MUST have a good knowledge and understanding of both the Advantage Workstation and primary operating function of this software application. This will be accomplished through applications training and through the correct knowledge and application of User Guide content. Please contact your GE representative to order and follow this mandatory training. A qualified individual is determined by the site. The site is the owner of the program and can be located within hospital, clinic, or private office setting (fixed or mobile) or wherever an AW Workstation, either a fixed or remote, is located. Make certain that your operator manuals are readily available at all times. Make a point to review procedures and safety precautions periodically. Additional safety concerns are addressed in the AW Volume Share 2 user guide and in the Volume Viewer 3.1 user guide. Safety notice legends:
THIS INDICATES A POTENTIALLY HAZARDOUS SITUATION WHICH, IF NOT AVOIDED, COULD RESULT IN DEATH OR SERIOUS INJURY.

This indicates a potentially hazardous situation which, if not avoided, may result in minor or moderate injury. Notice This indicates a nonhazardous situation which, if not avoided, could result in equipment damage, lost time, or reduced image quality.

GE Healthcare Intended Use

Advanced Vessel Analysis II is intended to provide an optimized non-invasive application to analyze vascular anatomy and pathology and aid in determining treatment paths from a set of Computed Tomography (CT) Angiographic images. Advanced Vessel Analysis II (AVA II) is a post processing application option for the Advantage Workstation (AW) platform, CT Scanner or PACS stations, which can be used in the analysis of 2D and 3D CT Angiography images/data derived from DICOM 3.0 compliant CT scans for the purpose of cardiovascular and vascular disease assessment. This software is designed to support the physician in assessment of aneurysms with or without thrombus (false lumen) for size and volume measurements with the capability to track the size and volume over time, stenosis analysis, pre/post stent planning and directional vessel tortuosity visualization. AVA II automatic visualization tools provide the users with the capabilities to facilitate segmentation of bony structures in the brain and neck and other vascular areas for accurate identification of the vessels. Once vessels are visualized, tools are available for sizing the vessel, analyzing calcified and non-calcified plaque to determine the densities of plaque within a coronary artery, measure areas of abnormalities within a vessel (like stenosis, plaque, thrombus, dissection or leakage). Also included within AVA II, is the ability to compare a patients previous exam to their current exam in order to measure and track any changes over time of their vascular structures. After review of the exams, there are multiple ways to film, archive and capture information for future review.

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VESSELIQ XPRESS/AVA XPRESS IS A SUPPLEMENTARY TOOL MEANT TO COMPLEMENT DIAGNOSIS OR TREATMENT BASED ON CLASSICAL TECHNIQUES. CHECK THE CONSISTENCY OF THE LOOK UP TABLE (LUT) ACCORDING TO THE ANATOMICAL STRUCTURES.

Patient Confidentiality
The equipment on which this application runs includes one or more hard disk drives, which may hold medical data, related to patients. Such equipment may in some countries be subject to regulations concerning the processing of personal data and the free circulation of such data. It is strongly recommended that access to patient files be protected from all persons not in medical attendance.

Volume Viewer 3.1

VesselIQ Xpress / AVA Xpress is an optional software extension of the Volume Viewer 3.1 application and uses several of the features of this application. When using VesselIQ Xpress / AVA Xpress you should be fully familiar with these features and the relevant safety information from the Volume Viewer 3.1 user documentation.

Image Requirements
It remains the responsibility of the physician to determine whether the inter-slice distance of a given exam is acceptable for use with VesselIQ Xpress / AVA Xpress. Always bear in mind that, within an exam, details with dimensions in the order of or less than the inter-slice distance cannot be identified with an acceptable degree of reliability. 3DXR models should always be analyzed and quantified in relationship with the original 2D Xray series. In all cases, the original 2D series should remain the reference. VesselIQ Xpress / AVA Xpress has not been validated for the quantification of aorta aneurysms or renal arteries from 3DXR models, and should NOT be used in these cases. It is recommended NOT to use VesselIQ Xpress / AVA Xpress in cases where an opacified catheter is present in the vessel segment to be analyzed.

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Views and Controls
The following types of views are used in VesselIQ XPress: Lumen view Oblique view Curved view.

(Refer to the Volume Viewer 3.1 User Guide for descriptions of these type of views)

Lumen. This transformation results in geometrical distortion of the displayed anatomical features because the successive intersections are not parallel. For this reason the Lumen view should NOT be used for diagnostic purposes by itself, but always in combination with other views.

The window width and level (W/L) settings determine how clearly pathologies and other anatomical structures present in the current 3D model can be discerned on the views. Incorrect W/L settings may result in pathologies and other essential anatomical structures not being displayed correctly, or even not being displayed at all. A single W/L setting cannot always clearly display all features present in an exam. Where necessary, use several different settings to explore the exam data. Also note that thresholding (see the Volume Viewer 3.1 user documentation) removes all voxels with values outside the selected threshold range from the 3D volume. Any pathologies or other anatomical features removed in this manner can no longer be displayed, irrespective of the W/L settings. A 3D view is a two-dimensional projection on the screen of the 3D volume. There is no indication on a 3D view of how deep inside the 3D volume the 3D cursor is located. To prevent misinterpretation of the cursor location on the axis perpendicular to the viewing position, the user should always verify the cursor position by correlation with the baseline and reformatted views. To prevent misinterpretation when rotating oblique or 3D views, always use the orientation annotations and the reference image (orientation indicator) to keep track of the orientation of the slice plane or view direction with respect to the patients body (RAS coordinate system). The user should be aware of the limited spatial and density resolution of 10

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the clinical images processed with the VesselIQ Xpress / AVA Xpress protocol. When manipulating the data with different display modes, make sure that pathologies and other essential anatomical structures remain present. The 3D view is intended for orientation purposes only, NOT for diagnostic use. In some cases it may not include all parts of the vascular anatomy. In the case of CT images, it is specifically NOT intended to display the tissue around the enhanced lumen. When filming or saving the result of a curved reformatting operation, always include the view on which you have defined the trace in the record. Without this information it is impossible to interpret a curved reformatted view correctly. When using Volume Rendering, you should be fully familiar with its functioning and the relevant safety information as set out in the Volume Viewer 3.1 user documentation. In particular: An incorrect threshold setting, incorrect curve type (threshold mode), or incorrect opacity setting, can result in essential anatomy, or pathologies, not being visible on the views displayed in volume rendering mode. When using the Navigator software, you should be fully familiar with its functioning and the relevant safety information as set out in the Volume Viewer 3.1 user documentation. In particular: Using an incorrect threshold setting or incorrect threshold mode can result in pathologies or other essential anatomy not being visible on the navigator views. A navigator view is a two-dimensional projection on the screen of a 3D volume. On such a view there is no indication of how deep inside the 3D volume the 3D cursor is located. To prevent misinterpretation of the cursor location on the axis perpendicular to the viewing position, the user should always verify the cursor position by correlation with the other views. The Navigator software uses a conical projection (perspective). For this reason, the assessment of dimensions and distances on navigator views tends to be subjective. The user should always correlate apparent dimensions and distances on the navigator view with the other views.

Geometrical Accuracy
THE GEOMETRICAL TRANSFORMATIONS NECESSARY TO UNFOLD THE VESSEL, OR, IN OTHER WORDS, TO TRANSFORM THE 3-DIMENSIONAL CENTERLINE INTO A STRAIGHT LINE, RESULT IN A DEGREE OF GEOMETRICAL DISTORTION OF THE ANATOMICAL FEATURES IN THE 11

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LUMEN VIEW. THE 3D VIEW IS CLIPPED TO CLEARLY SHOW THE VESSEL TO BE ANALYZED AMONG THE SURROUNDING TISSUE, AND MAY NOT INCLUDE ALL PARTS OF THE VASCULAR ANATOMY. FOR THESE REASONS THE LUMEN AND 3D VIEWS SHOULD BE USED FOR ORIENTATION PURPOSES ONLY, NOT FOR DIAGNOSIS. Distance, angle and area measurements are valid only if all segments defining the measurement are longer than the inter-slice distance. The geometrical accuracies defined above, when related to vessel measurements, are valid only if the vessel diameter is larger than 2mm.

Measurements
MEASUREMENTS ARE USED AS A SUPPLEMENTARY TOOL TO CONFIRM DIAGNOSIS BASED ON CLASSICAL TECHNIQUES. Vessel Measurements Accuracy of cross-section distance measurements (minimum diameter, maximum diameter and mean diameter) should be +/- 10 % for vessels with a diameter between 10 and 20 voxels. It should be +/- 5% for vessels with a diameter greater than 20 voxels. Accuracy of cross-section area measurements should be +/- 40 % for vessels with a diameter between 10 and 20 voxels. It should be +/- 20% for vessels with a diameter greater than 20 voxels. Accuracy of volume measurements should be +/- 40 % for vessels with a diameter and a length between 10 and 20 voxels. It should be +/- 20% for vessels with a diameter and a length greater than 20 voxels. Accuracy should be better than +/- 10 degrees for angle measurements.

Manual Measurements The software calculates and displays measurements with a resolution of one decimal place (such as 0.1 mm, 0.1 degree, etc.). You should be aware that the real measurement accuracy is generally considerably less for a number of different reasons. To assess the accuracy of the measurements performed with Volume Viewer 3.1, you should be fully familiar with the section Measurement Accuracy in the chapter Measurements. 12

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Verification of Vessel Identification and Quantification Process
CORRECT VESSEL QUANTIFICATION IS CRITICALLY DEPENDENT ON SUCH FACTORS AS ACQUISITION IMAGE QUALITY, VOXEL SIZE (IMAGE RESOLUTION AND INTER-SLICE DISTANCE), ARTIFACT AND LOW CONTRAST. ANOMALIES MAY OCCUR BECAUSE OF LIMITATIONS IN THE AVAILABLE DATA. IT IS THE RESPONSIBILITY OF THE USER TO VERIFY THE RESULT OF THE VESSEL IDENTIFICATION AND QUANTIFICATION PROCESS BEFORE USING THE DATA FOR ANALYSIS. IN CASE OF INACCURATE QUANTIFICATION, USE THE EDIT SECTION TOOL.

Trajectory of Automatic Centerline Algorithm

IN DIFFICULT SITUATIONS, SUCH AS A VESSEL WITH A COMPLEX TRAJECTORY, OR VESSELS TOUCHING EACH OTHER IN THE IMAGES, THE AUTOMATIC CENTERLINE ALGORITHM MAY NOT ALWAYS FOLLOW THE CORRECT TRAJECTORY. THE USER SHOULD ALWAYS EXAMINE THE COMPUTED TRAJECTORY BEFORE MOVING ON TO THE NEXT STEP IN THE PROTOCOL, AND IF NECESSARY CORRECT THE RESULT EITHER BY MODIFYING THE CENTERLINE TRACE OR BY ADDING INTERMEDIATE POINTS AND REPEATING THE CENTERLINE DETECTION PROCESS.

Segmentation
BONE REMOVAL IS AN AUTOMATIC SEGMENTATION PROCESS THAT IS CRITICALLY DEPENDENT ON FACTORS SUCH AS ANATOMY COVERED, ACQUISITION PARAMETERS, CONTRAST INTENSITY AND PATIENT PATHOLOGY, AND MAY RESULT IN AN UNSATISFACTORY SEGMENTATION OF THE 3D MODEL. AFTER SEGMENTATION RESULT, PERFORM A VISUAL CHECK TO MAKE SURE BONES HAVE BEEN PROPERLY REMOVED AND NO ANATOMICAL STRUCTURES ARE MISSING. Make sure that displayed volume contours always match the correct segmentation. ALWAYS CHECK VISUALLY THE LUMEN AND THROMBUS SEGMENTATION RESULT TO ENSURE THAT THE STRUCTURES HAVE BEEN QUANTIFIED PROPERLY.

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Saving
Check the reliability of saved object according to original datasets after reloading and post processing (tracking, segmentation, measurements, quantifications, user annotations, user defined ROIs). WHEN SAVING THE IMAGES OR THE REPORT, AND BEFORE LEAVING THE APPLICATION, ALWAYS PREVIEW THE SAVED SERIES WITH THE HELP OF THE VIEWER TO CHECK THAT THE ARCHIVED IMAGES ARE THE ONES YOU WANTED PROVIDING THE BEST VIEWS OF THE SUSPECTED LESIONS.

Saving, Filming
When filming or saving images to help you perform diagnostics, always make sure orientation annotations and patient name are displayed on all views.

Annotations on Filmed or Saved Images

Although images without annotation may be suitable for teaching purposes, diagnosis should not be performed with such images.

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GE Healthcare SOFTWARE SAFETY-RELATED MESSAGES

Messages giving information and warnings relating to the current system status are displayed on the Advantage Workstation screens. Some of these messages may be related to safety issues. For example, a message may warn that a screen or printed image will be enlarged or reduced, and this must be taken into consideration when making a diagnosis. It is important that users take note of and act on the information given in these messages. The table below shows safetyrelated messages which may be displayed. In manuals intended for use in countries in which the onscreen language is different from the local language, the table shows the displayed messages and gives a translation in the local language. In manuals intended for use in countries in which the onscreen language is available in the local language, the table is not present.

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Image Requirements
VesselIQ Xpress / AVA Xpress accepts CT image sets and 3DXR exams (i.e., 3D models of type 3D OBJ generated with Advantage 3DXR). These must meet the same image requirements as those for the basic Volume Viewer 3.1 application. A CT image set to be used with VesselIQ Xpress / AVA Xpress should meet at least the following requirements: Field of view, matrix size and display center must be the same for all images in the set, Orientation and gantry tilt should be the same for all images in the set, Tilted acquisitions are not supported for right/left decubitus patient orientations, There MUST NOT be two images corresponding to the same location in the set, The set should include only AXIAL, SAGITTAL, CORONAL or OBLIQUE images. Other types such as screen saves, etc. are not supported, Inter-slice distance MUST be less than 10 mm. When loading a CT image set, the VesselIQ Xpress / AVA Xpress software uses the FIRST selected image in the Browser as a basis for using/discarding the other images selected for building a 3D model. For example, any images having a matrix size or gantry tilt different from that of the first selected image in the Browser are discarded. Although VesselIQ Xpress / AVA Xpress will accept and load CT exams with inter-slice distances up to 10 mm, in practice exams with such large inter-slice distances are not suitable for vessel analysis, because many vessels that are essential for the analysis have diameters that are significantly less than 10 mm. Inter-slice distances in the order of 1 to 2mm are generally acceptable. Advantage 3DXR exams generated with Advantage 3DXR can be loaded and processed with VesselIQ Xpress /AVA Xpress. Such exams normally use a 5123 matrix and isotropic voxels (volume elements with the same dimension along all three axes).

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Volume Viewer Tips

Arrows next to buttons indicate a drop down menu. Click the arrow to open and close these menus. Rest the cursor over a button and a tool tip appears describing the button function. Typically, click [Next] and [Previous] to navigate through the wizard panels. Watch the progress bar at the bottom of the desktop. It shows the task progress when loading data or images. To remove a measurement or annotation from a viewport, right-click on the annotation and select [Delete] or drag and drop it outside of the viewport. To change the cursor shape, the trace tool or always hide reference image complete the following steps: a) Open the [Display] tab and select [Display options]. b) Set preferences in [General] tab. c) Click again on [Display options] or click [X] to close the window. When mouse mode is set to Page/Rotate, Zoom or Roam, double click on the viewport to enlarge it and display it as full screen. Right-click to see short-cut pathways for several features, e.g. Save Image, Hide Reference Image, Create a Trace, Delete Trace, etc. Right-click over red annotation to see if there is a pull-down menu. Place the mouse cursor over DFOV or image location and left-click, right-click, or middle click and drag to change DFOV or image location. Place the cursor over red RAS coordinates, then click and drag to roam the image.

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VesselIQ Xpress Protocols

VesselIQ Xpress Protocol Description

Pre-Stent Aorta Analysis:

Use this protocol to analyze the Abdominal Aorta and associated vascular structures prior to a stent placement procedure. This protocol features automatic aorta tracking, auto bone removal. It also provides the key measurements necessary for pre-surgical planning.

Post-Stent Aorta Analysis:

Use this protocol to analyze the Abdominal Aorta and associated vascular structures following a stent placement procedure. This protocol features automatic aorta tracking, auto bone removal. It also provides the key measurements necessary to evaluate the stent position and monitor over time for any shifting or movement.

Renal Analysis:
Use this protocol to analyze the renal arteries and associated vascular structures. This protocol features auto bone removal, and is used to define the arteries to analyze, calculate stenosis and identify plaque.

Mesenteric Analysis:
Use this protocol to analyze the Mesenteric Arteries and associated vascular structures. This protocol features auto bone removal and is used to define the arteries to analyze, calculate stenosis, and identify plaque.

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VesselIQ Xpress Protocol Description

Thoracic Aorta Analysis:

Use this protocol for the analysis of the Thoracic Aorta prior to a stent placement procedure. This protocol provides key measurements for pre-surgical stent planning.

Bilateral Carotids Analysis:

Use this protocol to analyze pathologies of the Carotid Arteries. This protocol features auto bone removal and is used to define the arteries to analyze, calculate stenosis, and identify plaque. The user will be able to track both the right and left Carotid Arteries with this protocol.

Carotid Vertebral Analysis:

Use this protocol to analyze pathologies of the Carotid and Vertebral Arteries. This protocol features auto bone removal and is used to define the arteries to analyze, calculate stenosis, and identify plaque. The user will be able to track both right and left Carotid and Vertebral Arteries with this protocol.

Circle of Willis Analysis:

Use this protocol to analyze pathologies of the Circle of Willis Arteries. This protocol features auto bone removal and is used to define the arteries to analyze, calculate stenosis, and identify plaque.

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VesselIQ Xpress Protocol Description

Spinal Vessel Analysis:

Use this protocol for the analysis of the Spinal Vessels. A step-bystep guide is used to define the arteries to analyze, calculate stenosis, and identify plaque.

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Lower Extremity Simple and Detailed Vessel Analysis:

Use this protocol to analyze the lower extremity arteries. This protocol features auto bone removal and is used to define the arteries to analyze, calculate stenosis, and identify plaque. The user will be able to track the vessels in both the left and right lower extremities with this protocol.

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Upper Extremity Vessel Analysis:

Use this protocol to analyze the upper extremity arteries. This protocol features auto bone removal and is used to define the arteries to analyze, calculate stenosis, and identify plaque. The user will be able to track the vessels in both the left and right upper extremities with this protocol.

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General Vessel Analysis:

Use this protocol to analyze any arterial vessel. A step-by-step guide is used to define the arteries to analyze, calculate stenosis, and identify plaque. This protocol can be used for any anomalous vascular structure.

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Launching VesselIQ Xpress

Step What you select How or Why you select it

1 Select the exam and series to be analyzed from the browser.

2 You have two options to launch the application: Select the Volume Viewer tab or Select VesselIQ Xpress from the Applications area located on the left panel.

2 (cont.)

If VesselIQ Xpress is not listed in the applications area, click on the [More] button, and choose from the list of installed applications. If you still do not see VesselIQ Xpress listed, please contact your GE Field Engineer or GE Sales Representative to ensure this application is installed correctly.

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Step What you select How or Why you select it

To find the Vessel Analysis protocols either, Select the anatomic area of interest by clicking on the body part, or Select the appropriate anatomic tab.

To further filter the protocols (if needed), select the filter Vessel Analysis from the list of filters located at the top of the screen. You will see the Vessel Analysis protocols displayed on the screen.

5 To launch a protocol, simply left click on the protocol icon you want.

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VesselIQ Xpress Workflow

Step What you select How or Why you select it

Vessel Tracking
Provided in each Vessel Analysis protocol is a step-by-step guide that will instruct the user through each step. The workflow for each protocol is the same, however some protocols will vary in the number of steps. The following instructions will describe the basic workflow for Pre-Stent Aorta Analysis protocol.

1
(cont.)

Vessels to Analyze
Place the Start of section point first in order to track a branch, then deposit points in all the vessels of interest. To skip a vessel, simply left click the next vessel on the list, then place your point. To undo a deposited point, click on the check mark next to the corresponding vessel. Then redeposit the point in the desired location. To add a new start point, click on (Add Start Point). The vessels following this new start point will begin their centerline tracking from this new point. This tool is helpful for bypass grafts, extremity vessels, and anywhere where you do not want to use the original start point to begin your tracking. To re-label the graphs, right click and select the desired name from the label database. Hints: Placing the point in the center of the contrast

enhanced lumen on the 2D views, produces better tracking results, than placing the point on the 3D views. When placing the points, place the point in the distal portion as far as you want the vessel to be tracked.

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(cont.) There are additional features in Step 1 that maybe helpful with tracking difficult exams with heavy calcification, tortuous vessels, occlusion, or any other condition where the centerline tracking is more difficult. Multiple Points (Show Tracking) (Define Bifurcation) (Start Bridge)

Points Deposition

To remove all vessels, click on (Clear All). To remove the last point deposited of a vessel, click on (Clear last point) Please see the Glossary of Features at the end of this document for more details.

1
(cont.)

Protocol Configuration
If desired, a user can customize the Vessel Analysis protocol by adding or removing vessels of interest in the tracking list. Click on Protocol Configuration to open the panel. Then click on either (Add Branch), or (Remove Branch). By selecting (Add Branch), a Vessel Name list that is build into the software will open allowing you to add any vessel within this list to your protocol. By selecting, (Remove Branch), you can delete the vessel you have highlighted in the protocol-tracking list. In protocol configuration, you can also rename a branch selecting (Rename Branch), or save your new vessel list as a new Vessel Analysis protocol selecting (Save Protocol).

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(cont.) Actions and editing can also be performed directly on the centerline. When your cursor is NOT in point deposit mode, you may mouse over the centerline and left click to select and display that vessel. Click on the centerline with the right mouse button to open an on-view menu that allows you to delete and rename branch, and deposit bifurcation and bridge. Please see the Glossary of Features at the end of this document for more details on bifurcation and bridge.

Centerline actions

Right click on centerline

1
(cont.)

Edit
By selecting (Edit Trace), you can edit the centerline of the vessel. The trace is displayed on an oblique Lsection view (lower right of the screen). Point the mouse cursor onto the section, click and hold down the left mouse button, and drag the trace to the desired shape. Select (Undo edit) to revert to the previous trace if the result of the edit is not satisfactory. When finished editing a centerline click (Accept) to keep the changes.

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(cont.) The AVA preferences are accessible through the gear icon at the top-right of post/prestent protocols panel. It opens the panel Vessels Analysis Preferences. You can toggle the different options:
Removing bones in head/neck and Abdomen/Chest/Lower limbs protocols: Launching protocol, bones are automatically detected and removed. Automatically track iliacs in Aorta Analysis protocols: Launching protocol, the iliacs are automatically tracked. Automatically jump to step 2 after tracking iliacs in Aorta Analysis protocols: Launching protocol, the iliacs are automatically tracked and the Quantification step is the default panel displayed. Activate multiple points by default: By default, it is proposed to define a branch depositing several intermediary points. Activate advanced mode for bridges: this preference adds the possibility to define abridge point using a new label.

AVA Preferences

You can save the customized layout as the default layout for this step of the current protocol, using the (Save Default Layout) button: The left screen of this layout will be applied when launching the protocol. The right screen of this layout will be applied when (Show Tracking) has been activated. The (Reset Default Layout) button will delete the customized layout and the next update of the screen will apply the initial protocol layout on left and right screens. Note: Please refer to the VesselIQ Xpress/AVA Xpress feature list on page 6 for applicability. Click (Next) to proceed.

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GE Healthcare AVA Tools: Edit/Measure

At Step 2, the screens update to display the curved, lumen, oblique, x-sectional, and segmented Volume Rendering views for each branch traced. The views will be displayed based on the default layout for the protocol
(Refer to the layout section for additional layout options).

At this step, the user should review each branch of interest by rotating around the curved view, reviewing x-section and longitudinal views.
(Refer to the Volume Viewer 3.1 User Guide for Viewport control descriptions) The user should verify that the software has:

Identified the vessel correctly Quantified the vessel cross-section at each location of interest correctly

2
(cont.)

Wizard Panel
On the wizard panel there is a number of tools & measurement options:
(Compare) (Thrombus) Color Identification Stenosis/Aneurysm (Save State) Edit o Edit Trace o Edit Section Advanced o Advanced Views Measures o Manual Measurements o Predefined Measurements

Compare, Thrombus, Color Identification, Stenosis/Aneurysm are described in dedicated sections. Note: Please refer to the VesselIQ Xpress/AVA Xpress feature list on page 6 for 27

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applicability. Click the (Next) button to proceed once all desired measurements have been done.

2
(cont)

Edit trace/ Edit section

To edit a trace: Select (Edit trace). The trace is displayed on an oblique Lsection view (lower right of the screen). Edit Freehand mode: Point the mouse cursor onto the trace, click and hold down the left mouse button, and drag the trace to the desired shape.
Note: When you edit a centerline, changes done on parts common to several branches are applied to all branches.

To edit a cross section contour: Select (Edit Section). The outline of the contour at the current position along the centerline is shown on an oblique X-section view. Interpolation Manual contour edition on cross-sections is interpolated to a predefined range of neighbor cross-sections. Edit: Freehand mode: Point the mouse cursor onto the part of the contour to be modified, click and hold down the left mouse button, then drag the contour into shape. You may have to click and drag on several points of the contour to obtain the desired outline. Click-Click-Double Click mode: Deposit new contour points by left clicking and validating by double clicking. The smooth line that is passing by the points shall modify the contour accordingly. 28

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Note: When you edit a cross section contour, the changes are applied only to the currently selected branch. For a vessel with more than one branch you will have to select and edit each branch separately, including the parts that may be common with another branch.

Select (Undo Edit) to revert to the previous trace or contour if the result of the edit is not satisfactory. After editing either the centerline or the cross section contours, select (Accept) again to update the vessel analysis computation. Once you are fully satisfied with the results, select (Edit) to close the Edit panel.

2
(cont.)

Predefined Measurements
At this step, the wizard panel will have a series of points that the user is prompted to place. These will be located on the Predefined Measurements tab. The Pre-Stent Aorta, Post-Stent Aorta, and Thoracic Aorta protocols will only have this step, as these points are used to create the required measurements for stent planning such as: Min/Max/Mean Diameters Cross-section area Distance (length) Angle Volume The points listed in this section will vary depending on the protocol selected for the analysis, and they can be modified or changed depending on the users preferences.

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GE Healthcare Predefined Measurements deposition

Once the user has placed all points listed in this section, the software will generate the measurements and automatically add them to the report at the end of the protocol. Deposit the reference points on a 2D or 3D view at the locations indicated on the panel. The points listed and measurements created at this step can be configured if needed by the user. Click (Next) to proceed

2
(cont.)

Manual Measurements
In addition to the predefined measurements, a user may add additional manual measurements for diameters, distances, angle and volume measurements. If these measurements are added click Next to see the results and to save the data. To add a measurement, click on the Manual Measurements tab and select the type of measurement you require: Auto Diameter Manual Diameter Length 2 or 3 points angle Volume Min/Max length measurement You are prompted to place the necessary point(s). If you wish you can create new reference points for the coming measurements, either just a proximal reference point, defining a simple reference, or a proximal and a distal reference point, defining a double reference. A default name (label) is automatically added in the list in the protocol panel and a default abbreviation on the Lumen view.

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Note: In the case of multi-phase datasets, each time you deposit a Reference or Measurement point an equivalent point is automatically determined for each of the other phases. To check where the point has been placed on a given phase, switch to this phase.

2
(cont.)

Types of Measurements
You can add the following types of quick measurements:
[Auto Diameter]: the computed mean diameter and cross section area for a point along the vessel centerline, [Manual Diameter]: distance between two points. This will usually be a diameter (e.g., the actual vessel diameter in the presence of a thrombus where the automatic diameter measurement is that of the lumen) but you can also use this function to measure, e.g., the distance between the vessel wall and nearby bone, [Length]: distance between two points located on the vessel centerline and measured along the centerline, [Volume]: volume of the section of the vessel between two points, [2 Point Angle]: angle between a section of the vessel, defined by two points, and the vessel centerline, [3 Point Angle]: angle between two sections of the vessel, defined by three points. The measurement is the angle between the segment defined by the first and second point and the segment defined by the second and third point. [Min/Max Length]: this feature allows you to calculate and display the minimum and maximum length on the wall of the vessel in addition to the length on the centerline of the vessel.

2
(cont.)

Modify measurements
To remove a manual measurement from the report, click on the gear icon. Then select the measurement you wish to remove and then click on the Remove) button. This will remove the measurement from the final Vessel Analysis report at the end of the protocol. A user may also change the name of a measurement by clicking on the (Modify) button. This will open another panel allowing the user to type in a new name.

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When all modifications are done, click on the (Close) button to return to Step 4 panel. Click the (Next) button to proceed

Configuring Measurement Points and Related Measurements

When configuring the protocol, a distinction is made between the measurement points and related measurements.
The measurement points are located on the centerline of the vessel and associated with measurements such as diameters and cross section area at that point. The related measurements refer to measurements between points, such as angles, or the length or volume of a section between two points.

To add a predefined measurement from the report, click on the (Configure Protocol) button.

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Select Ref. Points tab to configure the protocol reference points. To add a new point, select (Add) to open the Add a New Point panel.
The list of existing measurement points is

displayed. You can distinguish three types of points:

[No Diameter]: no diameter or cross section area measurements will be associated with the point. [Auto Diameter]: all diameter and area measurements for the point will be computed automatically by the software and included in the report. [Manual Diameter]: only a manually defined diameter (distance) measurement will be associated with the point. To perform such a measurement during analysis, you move the 3D cursor to the appropriate cross section, then place two points on the oblique Xsection view. You may want to include these instructions in the prompt text.

To modify or remove a point, select (Modify) and (Remove).

Configuring Related Measurements

Select Measurements tab to configure the measurements. The list of existing measurements is displayed. You can distinguish three types of measurements:
[Length]: distance measured along the vessel centerline between the two points. [Volume]: volume of the section of the vessel between the two points. [Angle]: angle between a straight line connecting the two points and the vertical

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(RAS coordinate system). [Min/Max Length].

To add a measurement:
Enter the necessary information in the two text fields. Select the measurement type: [Length], [Volume], [Angle] or [Min/Max Length]. To include only the measurement values in the report: set (Film) to off. To include both the measurement values and the corresponding images in the report: set (Film) to on. In the side-by-side lists, select (highlight) the start point in the From Point list, and the end point in the To Point list. You can only set up measurements between existing points. Select (Accept) to validate the new measurement.

To modify or remove a measurement, select (Modify) and (Remove). If you want to save the modified protocol for future use, select (Save Protocol).

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The last step is to view the report that is displayed in tabular form. The report length will vary depending on the number of measurements generated. You can view review each measurement by clicking on the slider bar located on the right hand side and scrolling up and down. At any time during the analysis, the user can click on the (Previous) button to return to a previous step and make any necessary corrections (such as adding or moving a measurement point, or changing an annotation. Note: Please refer to the VesselIQ Xpress/AVA Xpress feature list on page 6 for applicability

3
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Saving and filming

When done, click on the Select Output tab to export and/or save the report. A user has three choices: (Save) Saves the Vessel Analysis report as a new series on the AW browser attached to the current exam. This series can be exported as normal. (Save for Compare Mode) Saves the Vessel Analysis report, Save State, and VR Movie as three separate series on the browser attached to the current exam. These series can be used with the compare mode feature of VesselIQ Xpress. (Film) Sends the Vessel Analysis report to the filmer according to the format selected in the Film Format menu ([2x2], [2x3],) [2x4], [4x4], or [4x5],

Click on (Save) and the software will automatically compose and formats the report according to your choices. Note: Please refer to the VesselIQ Xpress/AVA Xpress feature list on page 6 for applicability. 35

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3
(cont.) To exit the VesselIQ Xpress software, simply click on the (Exit) button located in the lower left corner of the left monitor.

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VesselIQ Xpress Layouts

Layouts can be customized. Refer to "User Guide Volume Viewer 3.1 - Part 2", section "Customize your display" / "Free Format Layout for 3D")
Layout Left Monitor Views Right Monitor Views

1
Default Layout

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Quick AVA
Step What you select How or Why you select it

Quick AVA provides you with the capability to quickly perform quantitative analysis of a lesion from any 3D, Reformat, or Vessel Analysis protocol by a single click or two clicks. This means that you no longer have to start in a Vessel Analysis protocol in order have full Vessel Analysis capabilities. The Quick AVA buttons are available on the Segment or My Tools palette in Volume Viewer located on the left panel. Warning: If Quick AVA is launched within a Vessel Analysis protocol after vessel tracking has been performed, it will erase all tracked vessels, and start over.

Single Click Quick AVA:

A Single or one-click Quick AVA requires just a single click anywhere in the vessel of interest. From any Volume Viewer protocol, click the one-click Quick AVA button, and then click in the vessel of interest on any view. The software will automatically track the vessel in both directions proportionally to the diameter of the vessel.

Two Click Quick AVA:

A Two-click Quick AVA requires just two clicks anywhere in the vessel of interest. From any Volume Viewer protocol, click the two-click Quick AVA button. The software will prompt you to deposit two points, a Start point, and an End point. In between these two points, the software will track the vessel and calculate the centerline. 39

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Step What you select How or Why you select it

When the vessel has been tracked and displayed, the vessel name will be Vessel 1, annotated V1. The upper left image shows a 3D view of the vessel with the tracking superimposed on the vessel. Right click on the Red V1 annotation to access the Vessel names List, then move your mouse to the anatomy of interest, and choose a name from the list. The tracked vessel will be renamed from V1 to the name you selected from the list. This predefined vessel list is available anytime within Vessel Analysis. You can also access this list to configure your protocols making it easier and faster.

After tracking a vessel with Quick AVA, the left panel will update displaying the vessel list. Quick AVA is a tool that will launch the full Vessel Analysis software from anywhere. While using Quick AVA, you have access to all of the Vessel Analysis tools. Simply click on the corresponding button located on the left panel. Advanced
o Advanced Views Edit Trace Edit Section All Manual Measurements Color Identification Stenosis/Aneurysm

Edit
o o o o

Measures o

Color Identification, Stenosis/Aneurysm are described in dedicated sections.

(Refer to the Volume Viewer 3.1 User Guide for detailed descriptions of Advanced Views)

Click (Delete Traces) to erase any previously tracked vessel. Click (Start New) to track another vessel. 40

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Interactive Thrombus Extraction

Step Feature Description

1 Click the (Extract Thrombus) button (available in the AVA Tools: Edit/Measure panel in Step 2, the Extract Thrombus panel is displayed: 1. In the curved views, click the red text to angle/rotate both views to display the greatest amount of the thrombus then click (Add New Boundary) in the Semi Automatic Thrombus Extraction area of the panel. 2. Use the pen tool to mark the editable boundary (shown in red) of the thrombus.
3. Repeat these steps to add additional

boundaries to the thrombus (ideally 4 sides should be outlined).

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2
4. When you are satisfied that you have

accurately drawn the boundaries of the thrombus, click (Extract Thrombus). Several views are displayed, including:

Two 3D views with the thrombus highlighted (see on the left) Lumen view with the thrombus measurements displayed Coronal view Two curved views Several oblique views of the thrombus (depending on the size of the thrombus).

5. To manually edit the contours of the thrombus, click (Edit Contours) in the Manual Thrombus Editing area of the panel then leftclick on the boundary of the contour in one of the oblique views. Hold down the left mouse button to redraw the contour of the thrombus for the selected crosssection. 6. To extend the edition to the neighbor contours, adjust the interpolation using the slider in the protocol panel and edit the desired contour on one of the oblique views. Once the contour is edited, the software will automatically propagate the edition to the neighbor contours. 7. Repeat steps 5 and 6 for other oblique views to correct the contours of thrombus at other sections along its length. 8. Click (Accept) to accept the edit and redraw the views to reflect the edited contour. The thrombus volume is updated in the panel. To undo an edit, click (Undo Edit).

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Side By Side Comparison Mode

Side By Side Comparison Mode (SBS) allows two VesselIQ Xpress exams to be compared at the same time. Images from the older exam will be displayed on the right Monitor, and the current exam will be active in a VesselIQ Xpress protocol and displayed on the left Monitor. To allow comparison, the old exam needs to be saved in compare mode format and the original old exam with the series needs to be loaded on the workstation. To save an old exam in compare mode format: 1.Select the old exam in the patient list and complete Steps 1 to 3 of the VesselIQ Xpress protocol chosen for the current exam. 2.At the end of protocol Step 3, click (Save for Compare Mode) to save the old exam in both standard AVA report format and in compare mode format. Save for compare mode will save three series, and each of the first two series will need to be labeled during the save process.

To use Side By Side comparison: 1. Complete Step 1 of the chosen VesselIQ Xpress protocol for the current exam. 2. Click (Compare) in the step 2 protocol panel. 3. Select the Save State corresponding to the previous saved old exam in compare mode format. 4. Click (Load): left monitor displays the new exam while right monitor displays the old exam. 5. Use the old exam (measurements and associated images) to help you define measurements for the new exam.

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Color Identification
Step Feature Description

The Color Identification function enables you to create a colorcoded volume along the centerline of a defined vessel section. The vessel will be colorized up to the maximum diameter. The function is available for all Vessel Analysis protocols. To use the Color Identification function: 1. Click the (Color Identification) button 2. Click on view to deposit the first point, 3. Click on view to deposit a second point: a color ramp is automatically applied around the segment defined by the two deposited points. It is displayed in all reformatted views as well as curved and oblique views. 4. Click the plaque diameter annotation to modify the diameter of the plaque and grab Start and End points on the lumen view to modify the length of the plaque, 5. Click the plaque name annotation to display a dropdown menu allowing you to send the plaque to the Report, to delete the plaque, or to select another deposited plaque. A discrete color ramp with four segments is displayed on the left hand side of each view (except lumen and 3D views). The color ramp defines a color for a range of voxel values.

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Stenosis and Aneurysm Tools

Feature Description

To measure a stenosis:
1. When available in the protocol, click (Stenosis). 2. Place the start and the end points by clicking on any view. Then the software calculates automatically where the min diameter point is. 3. The stenosis measurements annotation is displayed on Reformatted and Lumen views along with the length, area, percentage and minimum diameter of the stenosis, as well as the type of the reference point used (i.e double or simple). You have the ability to move any point by clicking and dragging its associated line on the lumen view. 4. If needed, repeat step 1 to step 3 to calculate additional stenosis measurements. The 3D and Lumen views will update and the stenosis measurement annotation menu on Reformatted views will allow you to delete the selected measurement or switch to another measurement. 5. Click (Next) to move to the next step in the protocol. You place the start and the end points, then the software calculates where the min diameter point is. At this point, the user needs to move or adjust where the reference point is by moving the line on the lumen view On completion of all steps of the protocol, the exam report will include stenosis measurements and additional stenosis images. To delete a stenosis measurement, rightclick on its annotation and select (Delete).

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To measure an aneurysm, proceed as in the
stenosis tool using the (Aneurysm) button. Start point, end point and maximum diameter of the aneurysm are calculated and displayed automatically (as with the Stenosis tool). The aneurysm measurements annotation is displayed on Reformatted and Lumen views along with the length, area, percentage and maximum diameter of the aneurysm. To delete an aneurysm measurement, rightclick on its annotation and select (Delete).

Measurement computation using single/double reference point

To compute the stenosis/aneurysm measurements, you have the ability to choose a simple reference point (distal or proximal) or a double reference point by rightclicking its annotation. The annotation under Stenosis/Aneurysm on Lumen and Reformatted views informs the user that reference point has been used for computing the measurements. With a proximal reference point (first point deposited), the measurements are computed relatively to the proximal point. With a distal reference point, the measurements are computed relatively to the distal point. With a double reference point, the measurements are computed relatively to the interpolated value between proximal and distal points

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Views And Controls

LUMEN VIEW

A Lumen view is constructed by transforming the three-dimensional centerline into a straight line and then displaying for each point of the centerline the intersection with the plane perpendicular to the centerline.

Graph
The graph on the right side of the Lumen view can show the section area or the mean, minimum or maximum diameter. Note: The section area at a given point is the true cross section of the lumen at that point as computed by the software and as indicated by the green outline on the cross section oblique view. The mean diameter at a given point is defined as the diameter of a circle with the same area as the section area at that point. The minimum and maximum diameter at a given point are defined as the smallest and largest value, respectively, obtained when rotating the diameter measurement around the centerline. You use the drop-down menu linked to the curve type active annotation on the right of the view to select which value is displayed. From this menu you can also rescale the curve to display a range of 47

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values around that corresponding to the current cursor position, or reset the scale to display the full range.

OnView Menu
You use the on-view menu by clicking and holding right anywhere on the Lumen view (except for the red annotations. or the 3D cursor mark) and moving down to the required menu item. [Save Image]: saves the full contents of the view (Lumen view, graph, annotations) as a screen save. [Queue Report Image]: places the same information in a queue of screen saves, that will be added at the end of a report, when it is saved or filmed. [Clip to Width]: clips the associated 3D view to a tube around the vessel centerline with the same diameter as the current width of the Lumen display. [Enlarge]: enlarges the view, so that it takes up the entire viewing area. The menu item changes to [Reset Size] to return to the original size (one quarter of the viewing area). [Reset Pointer]: returns the 3D cursor to the center of the 3D volume.

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OBLIQUE VIEW
The oblique reformatted views that you use in Vessel Analysis are the same as in Volume Viewer 3.1, with the addition of a number of automatic modes to define the slice orientation: An X-Section view shows a reformatted slice that is perpendicular to the vessel centerline and contains the 3D cursor. A basic L-Section view shows a reformatted slice tangent to the vessel centerline at the location of the cursor line on the Lumen view, and parallel to the Lumen view at that point. When the Lumen view is rotated around the centerline, the L-section view rotates with it. The Best L-Section view is oriented so as to show as much of the vessel as possible for a given cursor position (plane of maximum curvature). The Dmin and Dmax L-Section views are oriented parallel to the plane containing the minimum and maximum vessel diameter, respectively, for a given cursor position. The vessel cross-section contour, and the minimum and maximum diameter are shown in green on the X-section view.

Oblique L-Section

Oblique X-Section

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Measurements
MEASUREMENT ACCURACY
This section summarizes the aspects concerning measurement accuracy that are applicable in particular to the measurements performed in Vessel Analysis.

Voxel Dimensions
The image set resolution, i.e., the dimensions of the voxels (volume elements) that constitute the image set, is determined by the size of the field-of-view, the matrix size and the inter-slice distance. In a typical CT image set to be used for vessel analysis, the voxel cross section in the acquisition plane will be in the order of 0.3x0.3 to 0.5x0.5mm for a 512x512 acquisition matrix and a field of view in the order of 15 to 25cm. Ideally, voxels should be isotropic (with the same dimensions along all three axes), i.e., the inter-slice distance should be the same as the voxel dimension in the acquisition plane. In practice, however, considerations such as patient irradiation dose levels will usually lead to the choice of a larger interslice distance. To reliably identify and measure small diameter vessels, that are significant for the analysis, an inter-slice distance in the order of 1 to 2mm is generally acceptable. You should be aware that details with dimensions in the order of or less than the inter-slice distance cannot be identified or measured with any degree of reliability.
Note:

Volume Viewer 3.1 accepts inter-slice distances up to 10mm, but such large inter-slice distances are of little if any use for vessel analysis. Advantage 3DXR exams normally use a 5123 matrix and isotropic voxels.

Geometrical accuracy
For CT image sets, the largest dimension of a voxel (normally the inter-slice distance) determines the geometrical accuracy: o For a distance measurement, the geometrical accuracy of the displayed length is equal to +/ largest voxel dimension, o For an angle measurement, the geometrical accuracy depends on the length of the segments, and improves as the length of the segments increases. As an example, for an angle measured between segments, which are five times larger than the largest voxel dimension, the geometrical accuracy of the displayed angle value is equal to +/ 10 degrees. o For an area measurement, the geometrical accuracy of the displayed area value is equal to +/ the circumference of the region of interest multiplied by (largest voxel dimension)2 / 2. For 3DXR exams, the geometrical accuracy is equal to +/ 0.2mm, irrespective of the acquisition field of view. 50

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The geometrical accuracy defines a lower bound on the overall accuracy that can be obtained. Further limiting factors are the vessel analysis quantification algorithm, acquisition accuracy, partial volume effects, display settings and display resolution.

Quantification Algorithm
The vessel quantification algorithm computes the vessel cross section contours at each point along the vessel centerline, on which the diameter, cross section area and volume measurements are based. This algorithm provides a best fit to the data available in the exam. However, the user should be aware that the limited spatial and density resolution of the clinical images processed with Vessel Analysis imposes limitations on the attainable measurement accuracy. Correct vessel quantification is critically dependent on such factors as acquisition image quality and voxel size (image resolution and inter-slice distance), and anomalies may occur because of limitations in the available data. It is the responsibility of the user to verify the result of the vessel identification and quantification process before using the data for analysis. For 3DXR data, the use of the appropriate injection parameters during 3DXR acquisition and proper patient immobilization are critical factors for the quantification accuracy. Refer to the Operating Manual for the vascular room and the Advantage 3D XR 2.0 Operation manual, for recommendations on 3DXR acquisition. 3DXR models are reconstructed from subtracted Xray images. For this reason an opacified catheter appears as a hollow cylinder in a 3DXR model, since it is opacified in both mask and image series. This may cause errors in the contours found by the quantification algorithm.

Acquisition Accuracy
Any errors resulting from the acquisition process that are present in the original image set (calibration and slice interpolation errors, motion artifacts) will be added to the same extent to the measurement error.

Multi-Phase Measurement Accuracy

In multi-phase datasets, the quality of the vessel analysis, quantification and measurement results for a given phase is critically dependent on the quality of the original acquisition for this specific phase. Before applying a vessel analysis protocol to a multi-phase dataset, the user should check for the presence of heart beat motion artifacts and other artifacts on axial and coronal images for all loaded phases.

Partial Volume Effects

In Xray exams (CT and 3DXR), the value of a voxel is the weighted average for all materials in the voxel. Because of the high attenuation coefficient of calcium, even a small amount of calcium in a voxel will weigh its value towards that of calcifications or bone, so that the entire voxel appears to be calcifications or bone. 51

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In vessel analysis, this partial volume effect will tend to make calcifications in the vessels appear larger than they are in reality, and hence affect the measurement accuracy.

Display Settings and Display Resolution

Since anatomical features are rarely of a uniform density, the apparent dimension of an anatomical feature can change when you change the display settings (window width and level). The measurements computed by the VesselIQ Xpress / AVA Xpress software are not affected by this, because the software does not rely on the display settings for vessel identification and quantification. However, when you place the measurement points yourself, e.g., for an additional diameter measurement, the apparent diameter can differ by one or more voxels depending on the W/L settings, thereby adding another factor of uncertainty. When four views are displayed on the workstation screen, each view has a display resolution of 512x512 pixels, and you obviously cannot place a manual measurement point with a precision better than a single pixel. Since most exams used for vessel analysis are based on a 512x512 acquisition matrix, display resolution normally does not impose a further limitation on accuracy, the more so because in most cases the display field of view (DFOV) for an analysis is smaller than the acquisition field of view.

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Glossary of Features
Feature Description

Multi-Points:
This feature will allow a user to place multiple points along the course of a vessel they wish to track. This is very helpful for tracking vessels that are highly diseased, tortuous, or not well enhanced.

Clear Last Point:

This feature will allow a user to clear the last point placed like an undo button. This could either be a single point, or if clicked multiple times, it will clear each last point placed when using the Multi-Points feature.

This feature will allow a user to Preview their tracking results before moving to the next step of the protocol. This feature can be used in two ways: As you are placing points, and you want to see the results of your work, you can click on the (Show Tracking) button and this will display the centerline tracking for all vessels that you have placed a point for up to this point. Or this feature can be on all the time, simply click in the empty box next to the button, you will see a check mark in the box indicating that this feature is on. Every time you place a point, the software will automatically track that vessel and display the tracking results. The tracking result display is the display of the tube along the centerline that contains the vessel on the 3D views and of the default layout on the right screen.

Show Tracking:

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4

Clear All:
This feature allows a user to clear all the points they have placed in order to start again from the beginning.

Define Bifurcation:
This feature allows a user to place an intermediate point to track a branch or a vessel segment directly from an existing centerline. 6

Bridge:
This feature allows a user to track across an occlusion in any vessel. This tool can be used with the Multiple Points tool to assist with tracking difficult exams. 7

Bridge Modes:
If at least one point has been deposited : Right-click on a branch annotation or start point annotation and select (Start Bridge) menu item Or selects a branch and click on the (Start Bridge) button, a pop down menu is opened to choose between current ( 1 ) or new label ( 2 ). 1/ Starting Definition of a new bridge in simple mode (from any view) Deposit any number of bridge you want., the current label is used. 2/ Starting Definition of a new bridge in advanced mode (from any view) Deposit any number of bridge points you want, a new label is used. A straight-line without quantification between bridge points is displayed without trying to identify the centerline of the vessel.

Edit Trace:
This feature allows a user to edit the centerline tracking of any vessel. A user can now edit their centerline at step 1 and step 2 of the Vessel Analysis 54

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protocols.

Edit Section:
This feature allows a user to edit the vessel diameter contours or sections. A user is responsible to verify the contours created by the software and make any necessary corrections prior to making measurements. Included with the feature, is the Interpolation tool. This allows a user to define how thick of an edit they wish to perform. 10

Compare:
This feature allows a user to compare exams side by side for comparison. Helpful with exams that are a follow-up to another previous exam. 11

Thrombus:
This feature allows a user to extract and measure the volume of a thrombus. This feature is only available in the Pre-Stent Aorta, and the Post-Stent Aorta Analysis Protocols. 11

Color Identification:
This feature allows a user to apply color to a section of vessel to analyze the densities of that area.
(Refer to the section Regions of Interest (ROIs/3D Analysis) of the Volume Viewer 3.1 User Guide Part 2 for detailed instructions on the color Identification feature)

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Stenosis/Aneurysm Analysis:
This feature allows a user to analyze a section of vessel for a possible stenosis or for a possible aneurysm. Both tools will provide the user with a variety of measurements that they will need to evaluate for both conditions. 55

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13

Advanced Views
The (Advanced Views) button allows you to rapidly access the most frequently used view types: [VR]: switch the 3D view to Volume Rendering mode, [VOI]: return the 3D view to the original volume of interest (tube containing the vessel), [X-Section]: switch the oblique view to Xsection (oblique cross section) mode, [Navigator]: display a Navigator view (upper left view), [MIP]: switch the 3D view to MIP rendering mode, [L-Section]: switch the oblique view to Lsection (oblique longitudinal section) mode.

14

Save State:
This feature allows a user to save their work, so that it can be loaded at a later time. This tool will save all tracking and measurements a user has performed prior to doing the save. A new series will be saved to the AW browser. 14

Help:
The question mark icon located on the left panel, will open a wizard panel with helpful definitions and instructions on how to use the features found within VesselIQ Xpress.

AVA Prefs:
This feature located next to the question mark icon, allows a user to configure the settings for AutoBone, Auto tracking, multiple points, advanced bridge mode, and default layouts within each VesselIQ Xpress protocol.
(Refer to the section CT scenarios/Abdominal Aorta Review with Autobone XPress and Carotid Review with AutoBone Xpress of the Volume Viewer 3.1 User Guide Part 3 for detailed instructions on using AutoBone)

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Glossary
3D Model The representation of the 3D (three-dimensional) image data in the workstation computer memory. 3D models can be saved, archived and networked (3D OBJ format). Usually, a 3D model is created by the software at startup from a CT or MR image set. However, saved 3D models, or 3D models generated by Advantage 3DXR can also be loaded and processed by the VesselIQ Xpress / AVA Xpress application. 3D OBJ Computer file format (Type in Browser series list), used to store a 3D Model on the workstation. Also used by Advantage 3DXR to store 3D data directly. 3DXR (3D Xray) Process of deriving 3-dimensional anatomical information by computer synthesis of X-ray data acquired at multiple angles by means of a vascular Xray system. Active Annotation A system annotation on a view that can be modified by the user to control certain viewing parameters (e.g., window width and level). Active annotations are displayed in red. Advantage 3DXR Software application used to derive a 3D data set from X-ray data acquired at multiple angles by means of a vascular Xray system. A data set generated by Advantage 3DXR uses the 3D OBJ format (3D object). Algorithm A step-by-step process used to solve a problem. In VesselIQ Xpress / AVA Xpress this refers in particular to the process used to identify (track) and quantify the vessel section to be analyzed. Annotation Generally, workstation-supplied text which accompanies an image when it is displayed on-screen, describing when and how that image was acquired, with what parameters. Also, text and measurement information added on a view by the user. Artifact Feature in an image resulting either from the initial data acquisition or subsequent computer processing that does not correspond to a real feature in the original anatomical structure. Also see Partial Volume Effect. Browser The window used to select available images for display and manipulation. CT (Computed Tomography) Process of deriving anatomical information by computer synthesis of X-ray data, acquired by means of a CT scanner in the form of parallel slices. CTA (CT Angiography) The use of CT techniques optimized for angiography. DFOV (Display Field Of View) The real dimensions of a view (width and height) with reference to the RAS coordinates. DICOM Abbreviation for Digital Imaging and Communications in Medicine. Standard for the formatting and exchange of medical images and associated information. Exam In CT, all images made from data taken of a patient after entering a particular scan cycle. In 3DXR, a 3D model generated by Advantage 3DXR. Field of View (Acquisition FOV) The area of the anatomy being imaged, usually expressed in centimeters. FOV image size is a function of the acquisition matrix times the pixel size. HU (Hounsfield Unit) Scale unit denoting voxel density in a CT data set. Image In this document the term image is used to designate the part of the exam data being processed and displayed on the workstation screen. Depending on the display settings, a view (q.v.) can display an entire image, or part of it (zoom). Measurement Annotation A user annotation on a view that shows the result of a measurement.

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MRA (MR Angiography) The use of MR techniques optimized for angiography. Partial Volume Effect The appearance of voxels with intermediate values at the interface (separating surface) between two tissue types with clearly distinct and different densities, where these voxels do not correspond to a real feature in the original anatomical structure. Pixel Abbreviation for picture element, the smallest distinguishable component of a digital image display. RAS Abbreviation for Right/Anterior/Superior. Designation for the patient-linked coordinate system used in CT and MR data sets. Reference Image Small image (normally displayed in the bottom right corner of a view) that graphically indicates the orientation of the image displayed in the view with respect to a baseline image (axial, coronal or sagittal). Rendering Techniques used to represent a threedimensional object on a twodimensional surface. System Annotation An annotation on a view added by the system software, containing data concerning the displayed image. Certain system annotations can be active, i.e., they can be modified by the user. Text Annotation A user annotation on a view containing text. Text annotations can be used to add comments, or to add a legend to an anatomical feature on a view. Toggle The act of switching a function from on to off, or off to on, with a single mouse click of the pointer on the functions button. Toggle buttons usually appear within windows and other monitor screen areas, but some keys on the keyboard may also provide toggle functions. User Annotation An annotation on a view added by the user, containing either text or the result of a measurement. View Part of the workstation screen, used to display image data. The view area of the VesselIQ Xpress / AVA Xpress screen normally contains four views. A view can display an entire image, or part of it (zoom). View Area During use of a viewing application, the portion of the screen(s) where images are displayed. The view area normally contains four views, but a single view can be enlarged so as to take up the entire view area. VOI (Volume Of Interest) In VesselIQ Xpress / AVA Xpress, the volume displayed in the 3D view that contains the selected section of the vessel to be analyzed. Voxel Abbreviation for volume element, the basic element in a CT or MR data set. Window (1) Describes the range of pixel values that are assigned a shade of grey. Narrow windows offer Greater resolution and contrast of anatomy having similar densities. It also helps you find the values for anatomy in which you are interested. Window (2) Window is also the term used for an on-screen graphical tool used to display information. Window Width and Level (W/L) In this context, window refers to the range of pixel values within the image data, that is assigned a shade of grey for display. Level refers to the center value, width refers to the range of pixel values displayed around this central level (twice the number of intensities above and below the currently set level). The adjustment is marginally similar to adjusting brightness and contrast controls: a narrow window (low width) translates to a high contrast of the display, and similarly a low level translates to a high value of brightness. See the AW Volume Share 2 Operator Manual for more details.

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