Real-time X-ray-based 4D image guidance of minimally invasive interventions



A new technology is introduced that enables real-time 4D (three spatial dimensions plus time) X-ray guidance for vascular catheter interventions with acceptable levels of ionising radiation.


The enabling technology is a combination of low-dose tomographic data acquisition with novel compressed sensing reconstruction and use of prior image information. It was implemented in a prototype set-up consisting of a gantry-based flat detector system. In pigs (n = 5) angiographic interventions were simulated. Radiation dosage on a per time base was compared with the “gold standard” of X-ray projection imaging.


Contrary to current image guidance methods that lack permanent 4D updates, the spatial position of interventional instruments could be resolved in continuous, spatial 4D guidance; the movement of the guide wire as well as the expansion of stents could be precisely tracked in 3D angiographic road maps. Dose rate was 23.8 μGy/s, similar to biplane standard angiographic fluoroscopy, which has a dose rate of 20.6 μGy/s.


Real-time 4D X-ray image-guidance with acceptable levels of radiation has great potential to significantly influence the field of minimally invasive medicine by allowing faster and safer interventions and by enabling novel, much more complex procedures for vascular and oncological minimally invasive therapy.

Key Points

• Real-time 4D (three spatial dimensions plus time) angiographic intervention guidance is realistic.

• Low-dose tomographic data acquisition with special compressed sensing-based algorithms is enabled.

• Compared with 4D CT fluoroscopy, this method reduces radiation to acceptable levels.

• Once implemented, vascular interventions may become safer and faster.

• More complex intervention approaches may be developed.

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The research is funded by DFG (German Research Foundation) grant (KA 1678/6-1 and BA 3546/2-1) and Siemens Healthcare. We acknowledge Stefan Sawall’s support in the creation of the reconstruction algorithm and his contribution to the discussion of the methodology. We thank Dr. Michaela Socher and Roland Galmbacher for animal handling. Furthermore, we would like to acknowledge Barbara Flach and Rolf Kueres for help during experimental set-ups and discussion of future developments. We would like to thank Dr. Michael Grasruck, Dr. Andreas Maier and Dr. Yiannis Kyriakou for extensive help with the experimental set-up, as well as discussion of applications, clinical implementation and future developments.

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Corresponding author

Correspondence to Sönke Bartling.

Electronic supplementary material

Supplementary video 1

Example of 4D intervention guidance of a guide wire in the right carotid artery of a full sized pig using colour-coded volume rendering. First the bent guide wire is visible in the external carotid artery, from which it is retracted into the common carotid artery. Here the guide wire tip is placed in front of the ostium of the ascending pharyngeal artery, into which it is then advanced. At all times the spatial position of the guide wire as well as its tip was clear (MPEG 880 kb)

Supplementary video 2

A movie of an unfolding stent protruding from the common carotid artery of a pig into the external carotid artery is shown. A volume rendering technique is used (MPEG 152 kb)

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Kuntz, J., Gupta, R., Schönberg, S.O. et al. Real-time X-ray-based 4D image guidance of minimally invasive interventions. Eur Radiol 23, 1669–1677 (2013).

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  • Intervention guidance
  • 4D imaging
  • Compressed sensing
  • Catheter lab
  • Minimally invasive