They Shoot Horses, Don’t They?

Ric HeerwaldMobile C-arms have never been considered replacements for stationary fluoroscopy rooms because their size and weight limitations restrict their repertoire.

Early versions were clumsy rolling tube stands pulling monitor carts with CRT displays. Their small multi-format cameras produced films showing up to four images on each 8- x 10-inch film cassette. They were typically composed of a stationary-anode x-ray tube along with a small image intensifier and a large transformer and could be powered from a common 120 V outlet. On their best day they could acquire images at 7.5 frames per second and store a total of 100 frames on an unreliable analog video disc.

In the mid 1980s, Orthopedic Equipment Corp (OEC) rapidly dominated the race for the mobile C-arm market. It first introduced a specialty C-arm—sold with orthopedic tables for hip replacements—that featured an improved x-ray tube with a rotating anode. OEC soon released a smaller and lighter high-frequency generator and expanded its product line to include a general surgery model; a model with neuro, vascular, and cardiac packages; and a model with extended surgery packages. OEC was then acquired by GE. A late entry in the race, Ziehm survived a sale of their Instrumentarium parent to GE, emerging as an endurance runner.

Few vendors could compete, and some thought the race for mobile C-arms had ended. At the November 2004 Radiographic Society of North America (RSNA) exhibits in Chicago, the field of mobile C-arms became much more competitive than it has been in recent years.

Philips has developed the Pulsera C-arm as a feature-for-feature competitor to GE/OEC. Siemens now has a contender with its Arcadis Orbic 3-D C-arm. This unit delivers 3-D reconstructions from rotational acquisitions, and soon its monitor station will double as a mobile picture archiving and communication system (PACS) viewing station. The monitor station for their Arcadis Varic model is already delivering PACS viewing features, though it has no 3-D capability.

The base of those utilizing mobile C-arm imaging has also expanded. From the original orthopedic surgeon enthusiasts to cardiologists and now to endoscopy and pain-management users, the mobile C-arm is gaining a wide range of support with perhaps its newest arena being minimally invasive surgery. As the base of utilization broadens, the flexibility and features of the equipment increase.

The problem is becoming, “How long do we continue to feed and clean up after the older horses that can no longer keep up with the young stallions in the race?” After 8 to 10 years, a C-arm system may still make images, but maybe it’s ready to be put out to stud as a parts machine. When we all want to ride the fine young stallions, do we continue to maintain service of the old units or send them to the glue factory?

The answer for the user is invariably “Give me the new foal. I don’t want that old nag on my ranch!” The answer for administration remains a question: “Can we afford the liability of keeping the old horse and losing races?” New technology is quickly making the cost of upgrading old units too expensive. Simple things like DICOM 3.0 interfaces, digital storage, and higher frame-capture rates are so expensive to scab on to older units that it’s making the purchase of new units more attractive. More sophisticated features, like 3-D capabilities and PACS viewing stations, complicate (or simplify) choices further.

The mobile C-arm race is becoming one of the most competitive races in surgery. Everyone wants to have the biggest and the fastest horse on the track. No longer is one thoroughbred company the only horse in the race. There are several new stallions with excellent features, and all are biting the bit to beat the champion.

The new champion will be the unit that can match the quality and speed of a vascular procedures suite with a flat-panel detector along with two flat-panel color monitors to function as a PACS viewing station. The stable producing this unit will be our new Triple Crown winner that sends the tired former champions out to pasture or—they shoot horses, don’t they?

Ric Heerwald is principal at Planning Resources, an equipment planning consulting practice in Richardson, Tex.