C-arms—a welcome addition to any ER or surgical suite—are changing the face of intraoperative imaging, assisting clinicians during orthopedic, vascular, and cardiac procedures. Mike Jasinski, senior vice president of sales and marketing at Ed Sloan & Associates in Goodlettsville, Tenn.; Patrick Kluge, technical director at Baltimore-based Rad Rays, LLC; and Lisa Reid, director of surgery and urology segments at Malvern, Pa-based Siemens Healthineers sat down with 24×7 to discuss this exciting—and emerging—imaging market. Don’t miss out.

24×7: The C-arm market is projected to see exponential growth in the next decade. What’s leading to such high demand?

Reid: There are a number of things. First of all, cost: Hospitals are looking to lower costs overall, and they’re finding that some of the newer C-arms with the more advanced technologies are able to fill in for hybrid ORs and some of the more advanced procedures that they need to do.

Jasinski: There are multiple drivers sustaining growth in the C-arm market.  For one thing, North America accounts for almost 50% of the global market, so it’s no surprise that the aging population is right up there. Also, geriatric orthopedics, as well as sports injuries due to today’s fitness culture, continue to boost demand. Hospitals are being measured on outcomes, and patient-driven demand for minimally invasive procedures is a part of this. We know, generally, that minimally invasive procedures lead to shorter recovery and better outcomes—particularly among the aging population. C-arm growth is also related to expansion in utilization for pain management, guided biopsy, arthrography, and even cardiac catheterization,

Today’s C-arms have more robust software capabilities. And when combined with the lighter-weight, more flexible positioning of the unit, larger hospitals are taking advantage of them and creating dual-purpose rooms. After all, they can perform routine angiography in an existing R&F space—and we all know how precious space is to hospitals. And let’s not forget that, above all, is the economic positioning of this technology; it’s eating into the angiography and catheterization space, as well as CT. By comparison, this platform is very inexpensive.

Kluge: C-arm imaging systems can be anything from a base-model orthopedic system all the way up to a cath lab on wheels. Cost points of new and used equipment will determine the affordability and repurposing of used equipment. High-quality used and refurbished image-intensifier-based systems can support the entry-level and median-priced market without having to step up to the very expensive first- and second-generation, flat-panel detector systems. On another note, a depreciated C-arm that will get the job done can add more value to the bottom line than a new, expensive system. New is not always better.

24×7: What are some the biggest challenges the C-arm market is experiencing? How is the industry working to overcome them?

Reid: I don’t really see any challenges, per say. But with the new, flat-panel detectors, one of the challenges has been that they’re a little bit more expensive than a standard image intensifier system. So I don’t think customers were budgeting for some of the more expensive [technologies]. But now that things have become more industry-standard, customers are looking to purchase these in order to fulfill and be able to do some of the procedures, such as vascular procedures, that the flat-panel detectors are being utilized for.

Jasinski: The market is not without its challenges—for one thing, it’s crowded with competitors. Although that’s not negative since it tends to drive innovation, it makes C-arms particularly sensitive to price pressures. This sensitivity to price pressure is not at all bad for everyone—we know that from observation and experience, and even the Transparency Research Corp. cited that refurbished equipment is expected to restrict new equipment sales in their 2015 market report. The ability of a focused, qualified provider to refurbish what have proven to be solid, reliable workhorse platforms, upgraded with the newest levels of digital technology, make a refurbished unit attractive when it can be acquired for as little as half the cost of a new unit. One segment’s problem is another’s promise.

Kluge: Still, the used market’s major challenge is selling a premium-quality, refurbished system against the large variance of competitors’ quality and price points. Buyers that shop for price, instead of quality, or simply rely on an Internet presence will pay more in the long run for a lesser system. Unfortunately, the term “refurbished” is very broad. The FDA understands this and is working on new guidelines for future regulation of third-party service providers and refurbishing companies. I’ve seen varying quality—or lack thereof—from other C-arm vendors.

Since we are an ISO and specialize on the OEC product line (aka: GE Healthcare) we get called in on the tough repairs and observe overlooked issues under the covers that we feel should have never been shipped to the customer. There are many quality companies out there in the C-arm business. Unfortunately, there are a few bad apples that supply limited recourse to customers. Rad Rays’ quality, however, is about as close as you can get to ‘OEM new.’.

24×7: What are some of the biggest innovations in C-arms right now?

Jasinski: C-arm technology continues to evolve to meet existing demands, and it’s creating its own new space as it goes. Lighter, more-maneuverable systems allow for placement in virtually any practice setting. With this capability, providers are able to meet the increasing, patient-driven demand for point-of-care health services.

There is the combined hardware-software developments, which allow these systems to deliver the highest levels of image quality at a lower, more trackable and controlled dose—and that speaks to patient safety, which today is at the heart of delivering x-ray-based imaging. With all of this, the C-arm continues to expand into more applications and procedural areas. Ever-improving digital technology, live anatomical images, capabilities of 3D, and better visualization of foreign bodies are all increasing the need for C-arms in both the ER and surgical suite.

Kluge: The biggest innovations in the C-arm market at this time include digital detectors, LED/LCD monitors, and optimizing pulsed fluoroscopy. This equipment is designed to have high image quality, possibly a dose reduction to the patient, as well as consistent video display characteristics for years. Unlike cathode ray tube (CRT) monitors, the LED/LCD monitors are not susceptible to phosphor burn-in. Currently, the downside to the monitor technology shift is that older systems lack the support of CRTs, due to end of life.

Certain CRTs are not available and will never go back into production. OEMs want you to go ahead and junk the system or pay a hefty price tag. Aftermarket LED/LCD kits are becoming available to maintain and refresh systems that should not go to the boneyard. I, personally, would not give up on a good C-arm that needs monitors during this time of technological transition.

Reid: In my opinion, the biggest thing is adding the flat-panel detectors to the C-arms. It’s really the last modality to have flat-panel detectors—and with that, and the growth in minimally invasive surgeries and vascular imaging, the flat-panel detector market is definitely taking off.

24×7: What else should biomedical engineers—those likely tasked with repairing C-arm equipment—know about these devices?

Kluge: The biomed first look is the answer; it has to be an easy fix. Unfortunately, we are at a point in technology where the manufacturer has the upper hand in locking biomeds and third-party service providers out of repairing the systems that were purchased for the hospital. Did the OEM salesman disclose the lack of serviceability to the C-suite? Or simply attempt to sell multi-year contracts? Hmm. Or for service, did the salesman sell training with minimal access? Hmm. With the ‘next-generation’ systems under lock and key, or for every ‘dongle there is a code.’ Hospitals need to save money; that is the prime directive. So engage!

Reid: I think the growth is leaning more toward the newer flat-panel detectors, and some companies—including Siemens—offer 3D C-arms. So the technology is getting more advanced in relation to a lot of the software capabilities. I don’t necessarily know that the technology is becoming more complicated; some of the C-arms are now water-cooled, which may make them a bit more difficult to service. But I think overall the hardware technology hasn’t changed that much, with the exception of flat-panel detectors and the 3D technology.