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Segmentation is an important problem in various applications. There exist many effective models designed to locate all features and their boundaries in an image. However such global models are not suitable for automatically detecting a single object among many objects of an image, because nearby objects are often selected as well. Several recent works can provide selective segmentation capability but unfortunately when generalized to three dimensions, they are not yet effective or efficient. This paper presents a selective segmentation model which is inherently suited for efficient implementation. With the added solver by a fast nonlinear multigrid method for the inside domain of a zero level set function, the over methodology leads to an effective and efficient algorithm for 3D selective segmentation. Numerical experiments show that our model can produce efficient results in terms of segmentation quality and reliability for a large class of 3D images.

Many effective models are available for segmentation of an image to extract all homogenous objects within it. For applications where segmentation of a single object identifiable by geometric constraints within an image is desired, much less work has been done for this purpose. This paper presents an improved selective segmentation model, without `balloon' force, combining geometrical constraints and local image intensity information around zero level set, aiming to overcome the weakness of getting spurious solutions by Badshah and Chen's model [8]. A key step in our new strategy is an adaptive local band selection algorithm. Numerical experiments show that the new model appears to be able to detect an object possessing highly complex and nonconvex features, and to produce desirable results in terms of segmentation quality and robustness.

Computer-based simulation for interventional radiology training has attracted increasing attention in recent years because of its potential to train remotely from patients and to provide objective assessment of proficiency. Yet developing a high fidelity simulator with realistic tactile feedback requires accurate knowledge of forces exerted on medical devices during interventional radiology procedures. This paper presents the development and validation of a force sensor for the measurement of axial forces generated during needle, and combined cannula/trocar, puncture procedures in patients. In order to assess the performance of this sensor, in vitro measurements were obtained using needle penetration of porcine liver, kidney and muscle. The results were compared with forces measured by means of a tensile tester. Calibration results showed that the force sensor has high sensitivity and linearity. Comparison of the force profiles obtained from the sensor and the tensile tester shows that good agreement was achieved in the in vitro studies for all the tissues tested. Preliminary clinical force measurements during arterial puncture and liver biopsy procedures have been performed in patients. An example of force recording for each procedure type is presented.

Guidewire insertion is an imperative task of minimally invasive medical procedures. During the procedure, surgeons need to steer long flexible thin wires through patient's blood vessels to reach a clinical target. In this paper, we present a novel approach to model haptics of guidewire insertion process for training simulation. The algorithm also allows for the analysis of the insertion process through subtle physical behaviours of guidewires via force feedbacks. The method includes a 6-DoF dynamic coupling between a rigid body, i.e. the virtual tool and the deformation of the wire simulated as an elastic rod. Instead of using the frictional contact force or the acceleration of the guidewire tip for haptic feedbacks, we compute constrained forces by directly connecting the virtual tool to the end of the guidewire. Therefore, the coupling scheme transmits haptic interactions through constrained dynamics between the virtual tool and the guidewire. Both positional and rotational control modes are implemented and evaluated with respect to the dynamics of the guidewire, user inputs and feedback forces. Experiments highlight the usability of our algorithm for an insertion procedure simulation with complex blood vessel structures. Copyright © 2011 John Wiley & Sons, Ltd.

Simulating intrinsic deformation behaviors of guidewire and catheters for interventional radiology (IR) procedures, such as minimally invasive vascular interventions is a challenging task. Especially real-time simulations for interactive training systems require not only the accuracy of guidewire manipulations, but also the efficiency of computations. The insertion of guidewires and catheters is an essential task for IR procedures and the success of these procedures depends on the accurate navigation of guidewires in complex 3D blood vessel structures to a clinical target, whilst avoiding complications or mistakes of damaging vital tissues and blood vessel walls. In this paper, a novel elastic model for modeling guidewires is presented and evaluated. Our interactive guidewire simulator models the medical instrument as thin flexible elastic rods with arbitrary cross sections, treating the centerline as dynamic and the deformation as quasi-static. Constraints are used to enforce inextensibility of guidewires, providing an efficient computation for bending and twisting modes of the physically-based simulation model. We demonstrate the effectiveness of the new model with a number of simulation examples.

This study evaluates AngioJet thrombectomy of occluded autogenous dialysis fistulae and polytetrafluoroethylene (PTFE) grafts in a UK hemodialysis population. Comparison is made with published data of alternative percutaneous thrombectomy methods. All patients with occluded dialysis fistulae who sought care at the Royal Liverpool University Hospital between October 2006 and June 2008 were included in the study. All patients were treated with the AngioJet Rheolytic Thrombectomy Device (Possis, Minneapolis, MN). Demographics, time of occlusion, adjunctive therapies, complications, and follow-up data have been prospectively recorded. A total of 64 thrombectomy procedures were performed in 48 patients. Forty-four autogenous fistulas were treated in 34 patients (19 brachiocephalic, 8 radiocephalic, and 7 transposed brachiobasilic). Twenty PTFE grafts were treated in 14 patients (9 brachioaxillary, 3 brachiocephalic loop grafts, 1 brachiobasilic, and 1 femoro-femoral). The average length of occlusion was 24 cm. Average time to intervention was 4 days. Immediate primary patency was 91%. Primary patency at 1, 3, and 6 months, respectively, was 71%, 60%, and 37%. Secondary patency at 3, 6, and 12 months was 87%, 77%, and 62%, respectively. Angioplasty was carried out in all procedures. Patients required stent insertion in 34 of the 64 thrombectomies to treat angioplasty-resistant stenoses. Complications included a puncture-site hematoma, and three angioplasty-related vein ruptures in one patient, all treated with covered stent grafts. Two cases of distal brachial arterial embolization were successfully treated by thrombosuction. AngioJet thrombectomy in dialysis access occlusion is safe and effective, comparing favorably with other methods.

In the past few decades, medicine has started to look at the potential use of simulators in medical education. Procedural medicine lends itself well to the use of simulators. Efforts are under way to establish national agendas to change the way medical education is approached and thereby improve patient safety. Universities, credentialing organizations, and hospitals are investing large sums of money to build and use simulation centers for undergraduate and graduate medical education.

It is becoming increasingly difficult to learn interventional radiology (IR) skills because there are fewer "straightforward" invasive diagnostic imaging studies, a reduction in the time available for training, concerns about patient safety, and changing patient perceptions. Computer-based simulation has the potential to allow an operator to realistically perform a virtual procedure with feedback about performance and could remove at least some of the patient's role during the learning curve. To do this effectively requires a strategy for integrating simulator models into curricula and the development of standards for their validation.

Training in interventional radiology (IR) relies on a traditional apprenticeship; to protect patients, expert supervision is mandatory until knowledge, attitudes and practical skills have been certified as satisfactory. However, the current quality of IR training is threatened by reduced time for trainees to learn, as well as a loss of basic diagnostic, training cases to non-invasive imaging. At the same time, IR techniques are becoming a focus of interest to a range of other clinical specialities. To address this training shortfall there is a need to develop novel training alternatives such as simulator models. Few simulator models in any medical field have been successfully validated to show improved clinical skills in treating patients. To date no endovascular simulator has met this standard. A good simulator must be based around key performance measures (metrics) derived from careful analysis of the procedure to be replicated. Metrics can be determined by trained psychologists from a direct analysis of the content of the job or task to be tested. The identification of these critical measures of performance is a complex process which must be tailored to a training curriculum to be effective. Simulators based on flawed metrics will invariably lead to unsatisfactory assessment. It follows that simulator development must involve the statutory licensing authorities. Equally it is essential that we do not assume that training on a particular simulator will correlate with the ability to perform the task in the real world. This "transfer of training" must be rigorously proven by validation studies.

The medical domain provides excellent opportunities for the application of computer graphics, visualization and virtual environments, with the potential to help improve healthcare and bring benefits to patients. This survey paper provides a comprehensive overview of the state-of-the-art in this exciting field. It has been written from the perspective of both computer scientists and practising clinicians and documents past and current successes together with the challenges that lie ahead. The article begins with a description of the software algorithms and techniques that allow visualization of and interaction with medical data. Example applications from research projects and commercially available products are listed, including educational tools; diagnostic aids; virtual endoscopy; planning aids; guidance aids; skills training; computer augmented reality and use of high performance computing. The final section of the paper summarizes the current issues and looks ahead to future developments.

We present a simulator for guided needle puncture procedures. Our aim is to provide an effective training tool for students in interventional radiology (IR) using actual patient data and force feedback within an immersive virtual environment (VE). Training of the visual and motor skills required in IR is an apprenticeship which still consists of close supervision using the model: (i) see one, (ii) do one, and (iii) teach one. Training in patients not only has discomfort associated with it, but provides limited access to training scenarios, and makes it difficult to train in a time efficient manner. Currently, the majority of commercial products implementing a medical VE still focus on laparoscopy where eye–hand coordination and sensation are key issues. IR procedures, however, are far more reliant on the sense of touch. Needle guidance using ultrasound or computed tomography (CT) images is also widely used. Both of these are areas that have not been fully addressed by other medical VEs. This paper provides details of how we are developing an effective needle guidance simulator. The project is a multi-disciplinary collaboration involving practising interventional radiologists and computer scientists.

Objective: to examine the effect of stent-graft deployment on pressure within an aneurysm sac and to investigate the potential sources of intra-sac pressure. Material and Methods: intra-sac pressure was monitored during and immediately after endovascular repair via an indwelling catheter. Intra-sac pressure was also monitored during conventional open repair and was compared with the pressure measured within patent lumbar and inferior mesenteric side-branches, both before and after restoration of iliac arterial blood flow. Intra-sac and side-branch pressures were recorded and expressed as ratios of simultaneously measured radial artery pressure. Results: in the absence of a graft-related endoleak (23/25 patients), endovascular repair resulted in a significant reduction in intra-sac pulse pressure (median ratio 0.31 IQR 0.10-0.46). There was no corresponding reduction in mean intra-sac pressure (median ratio 0.91; IQR 0.83-1.00). Application of clamps at conventional open repair resulted in a fall in both intra-sac pressure (median ratio 0.39, IQR 0.32-0.64) and pressure within side-branches (median ratio 0.45, IQR 0.33-0.64). Restoration of iliac blood flow resulted in a modest recovery of the side-branch pressure (median ratio 0.63, IQR 0.57-0.81), which nonetheless remained significantly less than the intra-sac pressure recorded after EVAR (p = 0.01). Conclusion: reperfusion of the aneurysm sac through patent side-branches seems insufficient to account for persistent pressurisation of the aneurysm after endovascular repair. This finding supports the hypothesis that pressure may be transmitted directly through stent-graft fabric. Eur J Vasc Endovasc Surg 25 , 354-359 (2003)

To determine aneurysm neck diameter change after endovascular repair (EVR) of abdominal aortic aneurysm (AAA) and its relationship to stent-graft diameter.The cases of 73 patients with AAAs who underwent EVR were reviewed retrospectively: 68 had preoperative imaging available. Neck diameter was reviewed by a single observer (M.F.B.) on preoperative, immediate postoperative, annual, and most recent contrast-enhanced computed tomographic scans. Baseline and follow-up neck diameters were compared with the manufacturers' values for unconstrained stent-graft diameters.Intraobserver error was 2 mm. Aneurysm neck diameter increased from 21.8 mm (range, 17-28 mm) at baseline to 22.8 mm (range, 19-30 mm) postoperatively and 25.8 mm (range, 19-31 mm; P.001) at a mean follow-up of 25.5 months (range, 6.2-60.8 mo). Neck diameter increase was more than 2 mm in 24 patients (33%). Mean change in the first, second, third, and fourth years was +1.63 mm, +0.52 mm, +0.25 mm, and +0.33 mm, respectively. Baseline mean stent-graft oversizing was 2.9 mm (13.7%; range, -1 to +8 mm), which decreased to 0.7 mm (range, -4 to +6 mm) at latest follow-up. Neck diameter exceeded stent-graft diameter (mean, 1.8 mm; range, 1-4 mm) in 21 cases (28%) and by more than 2 mm in five cases (6.8%). When neck diameter change was correlated with change in sac diameter, it was found to be insignificant (P =.24); however, it was significantly correlated with baseline oversizing (P =.01).After EVR, the aneurysm neck dilates, mostly in the first 2 years, by greater than 2 mm in one third of patients. This is possibly related to the presence of the endograft. The associated reduction of stent-graft oversizing warrants continued vigilance for proximal endoleak.

Carotid sonography is a well-established technique in the evaluation of patients with neurologic symptoms. We describe the case of a woman in whom duplex Doppler sonography of the extracranial carotid circulation showed high-velocity diastolic flow and a low resistance index without turbulence or morphologic abnormality of the artery. A suspected cause of this finding was low-resistance distal circulation secondary to low-resistance intracranial circulation due to an arteriovenous malformation. This diagnosis was later confirmed by CT. Because of the significant risk of bleeding associated with an asymptomatic intracranial arteriovenous malformation, duplex Doppler sonographic findings suggesting a low-resistance waveform in the presence of a morphologically normal carotid artery should prompt further imaging.

Objective: perianeurysmal fibrosis (PAF) with involvement of neighbouring viscera can render open repair of inflammatory aneurysms technically difficult and therefore hazardous. For this reason, endovascular repair (EVAR) has been advocated as the preferred approach for this condition. EVAR is known to induce a systemic inflammatory response in patients but the nature of the local response remains unknown. If significant, such a response could exacerbate rather than ameliorate PAF. The aim of the study was to examine the incidence, course and consequences of perianeurysmal fibrosis detected by computerised tomography (CT) before and after EVAR. Material and Methods: the clinical records of patients treated by EVAR and followed for at least 6 months were reviewed. Pre and post-operative CT images were independently graded for PAF by three radiologists according to a standard protocol. Results: PAF was documented preoperatively in six out of a total of 61 patients. In two of these PAF worsened after EVAR resulting in ureteric obstruction and hydronephrosis requiring ureteric stents. In the remaining 4 patients PAF did not reduce postoperatively. PAF of low grade developed postoperatively in 10 out of 55 patients (18%) in whom there was no evidence of PAF on preoperative imaging. Median follow-up was 18 months (range 6–36 months). The development of periaortic fibrosis de novo postoperatively was statistically significant (McNemar's test p =0.002). Conclusion: EVAR does not seem to reverse PAF if this is present preoperatively and it induces this condition in approximately one sixth of patients without evidence of preoperative PAF. The potential for this adverse inflammatory local response should be taken into account when considering EVAR for treatment of aneurysms with perianeurysmal fibrosis and must be weighed against the perceived benefits of this approach.

Objective to determine whether freedom from endoleak after endovascular repair of abdominal aortic aneurysm (EVAR) is a reliable guide to freedom from persistent or recurrent pressurisation of the aneurysm sac (endotension) and therefore freedom from risk of rupture. Patients and methods the records of 55 patients followed for more than 3 months after EVAR were reviewed to correlate the presence or absence of endoleak on contrast-enhanced CT and/or angiography with changes in maximum aneurysm diameter (DMAX). Results in 22 (40%) patients there was no significant change in DMAX during follow-up. In 21 of these no endoleak was observed on CT or angiography. One patient developed a secondary side-branch endoleak which remains under observation. In 18 (33%) patients, DMAX decreased during follow-up. Thirteen of these remained free of endoleak. Four patients developed secondary endoleaks which were treated by secondary intervention. One patient with persistent primary endoleak suffered fatal aneurysm rupture three days before planned intervention. DMAX increased in 15 (27%) patients. In only five of these could an endoleak be identified on CT and/or angiography. One primary side-branch endoleak persists following failed embolisation. Four secondary endoleaks have been corrected by secondary intervention. Four of the remaining 10 patients died suddenly from unknown cause. All had DMAX greater than 65 mm at last follow-up. One patient underwent late conversion, which suggested continued pressurisation through thrombus at the site of a ««sealed»» primary proximal endoleak. Two patients are scheduled to undergo embolisation of patent side-branches revealed only by Levovist enhanced Duplex scanning and three patients remain under observation. Conclusion freedom from endoleak on conventional imaging incorrectly suggested freedom from endotension in 10 (18%) of our patients. Follow-up after endovascular repair must include regular measurement of DMAX and/or aneurysm sac volume to identify those patients who remain at risk of rupture.

PURPOSE: To report the incidence of delayed complications following endovascular abdominal aortic aneurysm (AAA) repair and the relationship of these sequelae to morphological changes in the sac and endograft. METHODS: Twenty-six AAA patients treated with Vanguard endografts had completed > or = 1-year follow-up. Postoperative angiograms and spiral computed tomographic (CT) scans with 3-dimensional reconstruction were compared to the 1-year images to determine morphological changes in the aneurysm sac and the endograft. These changes were then related to complications occurring between 1 and 12 months postoperatively in the study group. RESULTS: Comparison of angiograms uncovered endograft buckling in 18 (69%) patients and acutely angled or kinked endografts in 10 (38%). Measurements from the CT scans found that undistorted endografts had a mean change in sac length of +6.6 mm. Mean sac length change in buckled endografts was -3.1 mm, while kinked endografts displayed a mean change of -6.2 mm (p < 0.002, Student's t-test). Five (19%) patients, all with distorted endografts, demonstrated late (1 to 12 months) complications (4 endoleaks and 1 graft limb thrombosis) owing to component separation, distal stent migration, and acute angulation. No movement in the proximal stent was observed. Elongation of the endograft (flow line measurement) was observed in one tube graft only. CONCLUSIONS: In this study, longitudinal shrinkage of the sac following endovascular aortic aneurysm repair led to buckling or kinking of the endograft within 1 year in 69% of patients. This appears to be an important source of delayed complications.

Medical simulators provide a risk-free environment for trainee doctors to practice and improve their skills. UltraPulse is a new tactile system designed to utilise focussed airborne ultrasound to mimic a pulsation effect such as that of a human arterial pulse. In this paper, we focus on the construction of the haptics component, which can later be integrated into a variety of medical procedure training simulators.

Radiology has evolved to become essentially two distinct but closely related fields: diagnostic and interventional radiology. The use of simulation is therefore diverse in its nature when applied to radiology. In the first part of this chapter, we present the role of simulation in diagnostic radiology, which includes not only its role for practitioner training but also its role as an education tool for our patients as they prepare to undergo potentially frightening noninvasive procedures. Simulation has been utilized in very novel ways for these purposes, and we believe much of this material will be of interest to the reader and may provide others with potential beneficial applications to a variety of other specialties. In the second part of this chapter, the role of simulation in interventional radiology is presented. Given the nature of invasive radiology and its grounding as a procedure-centric specialty, simulation in this field is more similar to other interventional fields and has shown great promise.

Interventional Radiology procedures (e.g., angioplasty, embolization, stent graft placement) provide minimally invasive therapy to treat a wide range of conditions. These procedures involve the use of flexible tipped guidewires to advance diagnostic or therapeutic catheters into a patient's vascular or visceral anatomy. This paper presents a real-time physically based hybrid modeling approach to simulating guidewire insertions. The long, slender body of the guidewire shaft is simulated using nonlinear elastic Cosserat rods, and the shorter flexible tip composed of a straight, curved, or angled design is modeled using a more efficient generalized bending model. Therefore, the proposed approach efficiently computes intrinsic dynamic behaviors of guidewire interactions within vascular structures. The efficacy of the proposed method is demonstrated using detailed numerical simulations inside 3-D blood vessel structures derived from preprocedural volumetric data. A validation study compares positions of four physical guidewires deployed within a vascular phantom, with the co-ordinates of the corresponding simulated guidewires within a virtual model of the phantom. An optimization algorithm is also implemented to further improve the accuracy of the simulation. The presented simulation model is suitable for interactive virtual reality-based training and for treatment planning.

The field of computer-based simulators has grown exponentially in the last few decades, especially in Medicine. Advantages of medical simulators include: (1) provision of a platform where trainees can practice procedures without risk of harm to patients; (2) anatomical fidelity; (3) the ability to train in an environment wherein physiological behaviour is observed, something that is not permitted where in-vitro phantoms are used; (4) flexibility regarding anatomical and pathological variation of test cases that is valuable in the acquisition of experience; (5) quantification of metrics relating to task performance that can be used to monitor trainee performance throughout the learning curve; and (6) cost effectiveness. In this chapter, we will focus on the current state of the art of medical simulators, the relevant parameters required to design a medical simulator, the basic framework of the simulator, methods to produce a computer-based model of patient respiration and finally a description of a simulator for ultrasound guided for liver biopsy. The model that is discussed presents a framework that accurately simulates respiratory motion, allowing for the fine tuning of relevant parameters in order to produce a patient-specific breathing pattern that can then be incorporated into a simulation with real-rime haptic interaction. Thus work was conducted as part CRaIVE collaboration [1], whose aim is to develop simulators specific to interventional radiology.

Recognition of the many limitations of traditional apprenticeship training is driving new approaches to learning medical procedural skills. Among simulation technologies and methods available today, computer-based systems are topical and bring the benefits of automated, repeatable, and reliable performance assessments. Human factors research is central to simulator model development that is relevant to real-world imaging-guided interventional tasks and to the credentialing programs in which it would be used.

Aim To establish how often off-label device and drug use occurs in interventional radiology (IR) in a UK tertiary referral hospital and consider the wider implications for the interventional radiologist. Materials and methods Prospective data were collected during interventional procedures for 1 working week in a university hospital. Out-of-hours procedures and procedures outside the department were excluded. Operators were asked to record the drugs and devices used, the indication, and method of use. The instructions for use/summary of product characteristics were then studied for each device/drug used to assess if the use was on or off-label. Results During the study period 52 cases were performed and data were available on 26 cases (50%). In 22 of the 26 cases (84%) there was evidence of off-label use of devices or drugs. Off-label use of drugs included treatment of venous malformations with Fibrovein © (sodium tetradecyl sulphate), which is licensed for the treatment of varicose veins in the leg, and intra-arterial injection of heparin, which is licensed for intravenous and subcutaneous use. Off-label device use included placing vascular sheaths in the urinary tract, using angiographic catheters to guide wires in the urinary tract, using sheaths for thrombosuction, reshaping of the tip of most guidewires, and using angioplasty balloons to dislodge the arterial plug at fistula thrombectomy. Conclusion Off-label device and drugs use is common in a UK tertiary hospital IR department and literature suggests this is common in the wider IR community. There are important clinical and legal implications for off-label use for patients and physicians.

A SensAble Omni force feedback device has been modified to increase the face validity of a needle insertion simulation. The new end effector uses a real needle hub and shortened needle shaft in place of the Omni's pre-fitted pen shaped end effector. This modification facilitates correct procedural training through the simulation of co-located visual and haptic cues in an augmented reality approach to simulation. The development of the new end effector is described and a pictorial guide to its manufacture and the fitting process is provided. Initial results from face validation studies bode well for the fidelity of this low cost device.

Debate on the existence of innate skills has all but evaporated in the light of evidence that it is only the hours spent in deliberate practice that correlate with even the most elite levels of expertise. A range of simple to advanced technologies stands to address some of the many challenges to effective training of 21st century, procedural medicine. Simulation could train and assess behaviours remotely from patients, in complete safety, reducing the risks of inexperienced trainees learning critical tasks in patients while contributing to certification and revalidation. Understanding the strengths and limitations of these devices, determining and improving their effectiveness and identifying their roles, as well as those of individuals and teams, represents a cornerstone of successful adoption into the interventional radiology curriculum. This requires a simulation strategy that includes standards for simulator documentation.

We present an integrated system for training ultrasound guided needle puncture. Our aim is to provide a cost effective and validated training tool that uses actual patient data to enable interventional radiology trainees to learn how to carry out image-guided needle puncture. The input data required is a computed tomography scan of the patient that is used to create the patient specific models. Force measurements have been made on real tissue and the resulting data is incorporated into the simulator. Respiration and soft tissue deformations are also carried out to further improve the fidelity of the simulator.

This paper reports on a low cost system for training ultrasound imaging techniques. The need for such training is particularly acute in developing countries where typically ultrasound scanners remain idle due to the lack of experienced sonographers. The system described below is aimed at a PC platform but uses interface components from the Nintendo Wii games console. The training software is being designed to support a variety of patient case studies, and also supports remote tutoring over the internet.

Interventional Radiology is a rapidly expanding speciality using minimally invasive techniques to treat a multitude of clinical problems. Current work in progress aims to create an affordable virtual training tool to reduce training times and patient risk during a trainee practitioners learning cycle. The procedure of arterial catheterisation has been broken down into a number of subtasks, one of which requires an operator to locate the femoral artery pulse by palpation. This is performed in preparation for a needle insertion to allow the entry of a guide wire and catheter into the patient. This paper presents the current state of research into a unique solution for affordable haptic simulation of pulse palpation in a virtual environment.

The original publication is available at www.springerlink.com; International audience; Purpose : We present here a simulator for interventional radiology focusing on percutaneous transhepatic cholangiography (PTC). This procedure consists of inserting a needle into the biliary tree using fluoroscopy for guidance. Methods : The requirements of the simulator have been driven by a task analysis. The three main components have been identified: the respiration, the real-time X-ray display (fluoroscopy) and the haptic rendering (sense of touch). The framework for modelling the respiratory motion is based on kinematics laws and on the Chainmail algorithm. The fluoroscopic simulation is performed on the graphic card and makes use of the Beer-Lambert law to compute the X-ray attenuation. Finally, the haptic rendering is integrated to the virtual environment and takes into account the soft-tissue reaction force feedback and maintenance of the initial direction of the needle during the insertion. Results : Five training scenarios have been created using patient-specific data. Each of these provides the user with variable breathing behaviour, fluoroscopic display tuneable to any device parameters and needle force feedback. Conclusions : A detailed task analysis has been used to design and build the PTC simulator described in this paper. The simulator includes real-time respiratory motion with two independent parameters (rib kinematics and diaphragm action), on-line fluoroscopy implemented on the Graphics Processing Unit and haptic feedback to feel the soft-tissue behaviour of the organs during the needle insertion.

In the ongoing evolution of a categorization system for endoleak, the authors propose the term endotension to define persistent or recurrent pressurization of the aortic aneurysm sac after endovascular repair. Endotension is evidence that the aneurysm remains at risk of rupture and should, therefore, be considered an indication for secondary intervention. Management strategies and a grading system for endotension are offered.

We present a prototype for a new virtual environment aiming at training interventional radiologists in the core skills involved in using catheters or guidewires. The instrument is modelled as a hybrid mass-spring particle system while the vasculature is a rigid triangulated surface mesh. A specially designed commercial haptic device allows the trainee to use real instruments to guide the simulation through synthetically generated vasculature with different degrees of complexity. Open source libraries are used for the visualisation and collision detection. Preliminary results show reasonable behaviour.

There exists little significant evidence on which to base the use of inferior vena cava (IVC) filters (1–3; see Table 1) and, at present, there are no UK or European regulatory guidelines for their use. They are therefore used on a case-by-case basis with moderate variation between centers. The Royal Liverpool University Hospital Interventional Radiology Department places about 12 IVC filters annually although a neighboring center with a much smaller population catchment area inserts at least twice as many each year. Even in the same unit there is a wide range of use between individual radiologists and referring clinicians. The incidence of use of IVC filters in the United Kingdom seems much less than in the United States. Although we can find no comparative data in the current literature, the incidence of filter use in the United States in recent years is well documented with 30,000 to 40,000 filters inserted per year (4).