C-Arm Systems

sunglowcitrineUrban and Civil

Nov 15, 2013 (3 years and 8 months ago)

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BUYER’S GUIDE TO MOBILE C
-
ARMS


Table of Contents

I.

Room Layout

................................
................................
................................
................................
.

2

II.

Procedures

................................
................................
................................
................................
....

4

III.

C
-
Arm
Systems

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................................
................................
...............................

5

IV

Procedure Tables

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................................
................................
.........................

16

V.

Patient Record Storage
................................
................................
................................
................

17

VI.

Radiation Protection and Safety

................................
................................
................................
..

19

VII.

Warranty

................................
................................
................................
................................
......

21

VIII.

Payment Options

................................
................................
................................
.........................

22

IX.

Delivery, Set
-
Up and First Use

................................
................................
................................
......

23

X.

Refurbished
or Not?

................................
................................
................................
.....................

24

XI.

Return on Investment (ROI)

................................
................................
................................
..........

25










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-
Arm

Marketplace

FOREWORD


T
he material
presented herein has been borne from years of experience in the used equipment
marketplace. From time spent as a consultant, sales person, marketing
manager and owner of a
company selling used C
-
Arms, I tried to assemble information that will help you to ma
ke an
informed decision. If
I’ve
accomplished that,
I’m h
appy. Whatever choice you make,
please use
this
Guide to do it and wish you the very best in the future.


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Arm

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I.

Room Layout

One of the questions we’re frequently asked is: Will the C
-
Arm fit in the room we’ve picked? Or, its
variant: What size room do we need to house the C
-
Arm and table?

Generally speak
ing, your procedure room should be at least 10 x 12 feet. It will be a tight fit with a
standard C
-
Arm and table, but they will fit and you should have enough room to maneuver around
and properly access the patient.

Drawing one illustrates the different
sizes of systems at various positions of the Arc.



DIMENSIONS OF C
-
ARMS (IN INCHES)

AREA

MEASURED

OEC 9400

BV 29

OEC 9600

ZIEHM
7000

BV 300

OEC 9800

BV
PULSERA

OEC 9900
ELITE

ZIEHM *
VISION R

2010+ BV
PULSERA

A

65.0

65.0

68.25

66.9

73.6

69.7

73.6

69.7

66.9

73.6

B

74.5

74.0

78.5

63.0

70.0

76.0

70.0

76.0

63.0

70.0

C

96.5

96.0

102.0

85.0

92.0

98.0

92.0

98.0

85.0

92.0

D

34.0

34.0

34.5

31.5

35.2

33.0

35.2

33.0

31.5

33.0


Dimension “C” is the one that will most likely determine the overall length requirement for your
room. As you can see, the OEC 9600 would need a minimum room length of 8.5 feet alone and
that’s using the system from wall to wall.


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-
Arm

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Other considerations f
or the room.



C
-
Ar
ms operate on 110 V, 12
-
15 Amps so a standard outlet is all you need. It is
recommended that you have a dedicated circuit for the C
-
Arm and plug nothing else into
this outlet (alleviates potential power spikes).



Do you have adequate lighting?



Do you have adequate cooling?


Remember, C
-
Arms get hot during Fluoro.


Shielding considerations:



Are there any walls of the procedure room that abut a common wall where there may be
pregnant women or children for prolonged
periods of time? If so, you may consider
shielding that wall.



Does your state require shielding for C
-
Arm use? Most states do not specifically require a
room be shielded. Sometimes, like in the case just above, their suggestion may be simply
installing
another layer of sheet
-
rock. We haven’t seen any case of state requiring leaded
walls for C
-
Arms. You can also buy, if so inclined,
5/8”
drywall with lead equivalency. It’s
fairly easy to hang and doesn’t cost much more than standard sheet
-
rock (drywall).




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Arm

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II.

Procedures


What you will use the C
-
Arm for, that is, the type of procedures is the first thing to consider.

Over the last three year

period, 87.5% of our customer purchased general surgical platform based
C
-
Arms and the remaining 12.5% purchased vascular. We have no sales of cardiac systems
although we had a few interested prospects, the wait to get one as well as the price pushed the
m
to buy new.

The reason for the predominance of the general surgery systems is simple: most of the units would
be used in pain management environments and the general surgery platform is all that is required.

For those doing stents and pacemakers, the

need for digital subtraction required them to buy units
with vascular options. No one, to the best of our knowledge, offers a general system with digital
subtraction. It would be a huge seller if they did, but the OEMs haven’t made that move yet
.



General Surgery



Aneurysm Repair



Pacemaker
Implantation



Hip Replacement



Foreign
-
Body
location




Needle Biopsy



Catheter
Placement



Percutaneous
Lithotripsy



Cardiac



Swallow Studies




Interventional
Neuroradiology



Neurosurgery



Trauma Care




How many procedures will the C
-
Arm be used for per week is an important consideration. The
typical volume we hear is 10
-
15 per week. For that, almost any C
-
Arm is fine. As you ramp up the
volume, especially per day, you need to consider the time it takes f
or the C
-
Arm to cool down
between procedures. This varies between models and manufacturers. In the broadest of terms, a C
-
Arm with rotating anode tube will cool faster and therefor have greater patient throughput. If you
schedule the 15 patients throughout

the week, there is no problem. When you get to the 15
-
20
procedures per day, or perform long Fluoro time procedures, you should give careful consideration
to the anode tube.

The entire line of standard sized OEC C
-
Arms has rotating anodes, as do the Puls
eras built after
2005. The Avantic and Vision R also have rotating anodes. Most others named above have
stationary anodes. And, regarding he Vision R, it should be pointed out that it is a pulse
-
based
system.

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-
Arm

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III.

C
-
Arm Systems


In making this Buyer’s Guide, we’ve tried to include as much data as possible on all types of
systems, however, there are really more than we could handle. That, combined with the fact that
many systems are simply not readily available on the used marketp
lace, we’ve purposely limited
our discussion of C
-
Arm systems to those that are generally available at most times.

The following

are the C
-
Arms you will most likely
find available

in the preowned equipment
marketplace. Understand that supply drives the bu
siness not demand. All the demand in the world
can’t make a particular system come available. It will increase the price, but it simply can’t make
one available.

Listed from oldest models to newest in each line, standard, compact and mini:


GE/OEC



OEC 90
00


9400


9600


9800


9900



OEC 7600


7700


7900
-

8800 Compacts



OEC 6600


6800 Mini C
-
Arms


Philips Medical



BV 25


26


29


300


300Plus


Libra


Endura


Pulsera
-

Veradius


Ziehm



Ziehm 7000, 8000, Vista, Vision R, Vision FD, Solo,



Zieh
m Quantum Compact


Siemens Medical



Siremobil ISO
-
C, ARCADIS Varic, ARCADIS Avantic, ISO
-
C
3D



Siremobil Compact L



Orthoscan Mini C
-
Arm (Distributor)




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ARMS

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-
Arm

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Foreign brands

(these are mostly available as new, but some used are entering the
marketplace.

Genoray
,
South Korea





Z
-
7 Z
-
2090


Lots of choices

as you can see
. But remember,
supply is the market driver
.

Here’s a
look at the USA market shares
:


OEC



68% Philips


20%


Ziehm


6
%

Siemens
-

5%


Others


1%


So, we can deduce and the mark
et bears this out, most C
-
Arms available on the preowned
marketplace are OEC branded, followed by Philips BV line.




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Arm

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Comparison of C
-
Arms


Despite the variety of units available, most C
-
Arms are eerily similar. Rather than focus on the many
attributes of the units, we prepared a comparison chart showing the key elements of each system
by the factors that contribute to image quality and usabil
ity.

Again, it doesn’t represent all the units available, but does cover the most likely to be purchased on
the preowned market. We’ll examine the generator power, tube types (rotating versus stationary),
camera types, focal spot sizes, monitors and the
ir respective pixel resolutions, depth of C, rotation
and angulation and pulsed fluoro rates (the latter being a key to reduced dose).









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Arm

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Generator Power


Generator power is directly related to the ability to penetrate dense anatomy, which is becoming
increasingly more problemsome due to obesity. Some companies, like Ziehm Vision R, use higher
mA to get better visualization at the same time reducing patient

dose by employing a constant
pulse mode.

GENERATOR POWER (kW)

OEC 9400

BV 29

OEC 9600

ZIEHM
7000

BV 300

OEC 9800

BV
PULSERA

OEC 9900
ELITE

ZIEHM
VISION R

2010+ BV
PULSERA

4.5

4.5

7.5

2.0

7.5

15

7.5

15

7.5

15


How much power do you need? It is generally considered that most Fluoro is accomplished at rates
that do not require significant power.

The typical fluoroscopic exposure is obtained at 70 kVp at a
rate of 2 mA.

Keeping the image at a constant brightness

can be achieved in two ways: varying the kVp and mA
to compensate for variations in patient and imaging conditions (automatic dose control) or by
adjusting the gain control on the video system.











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Arm

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TV Camera


All C
-
Arm manufacturers today utilize digital CCD TV Cameras in their systems. The only exception
being older OEC models such as the OEC 9000 and OEC 9400. Both these systems have Vidicon
analog cameras.

The use of CCD cameras
is a major technology advan
tage for digital imaging. Although CCDs are
not the only technology to allow for light detection, CCD image sensors are widely used in
professional, medical, and scientific applications where high
-
quality image data is required.

An image is projected thr
ough a lens onto the capacitor array (the photoactive region), causing
each capacitor to accumulate an electric charge proportional to the light intensity at that location.
A one
-
dimensional array, used in line
-
scan cameras, captures a single slice of the
image, while a
two
-
dimensional array, used in video and still cameras, captures a two
-
dimensional picture
corresponding to the scene projected onto the focal plane of the sensor. Once the array has been
exposed to the image, a control circuit causes each c
apacitor to transfer its contents to its neighbor
(operating as a shift register). The last capacitor in the array dumps its charge into a charge
amplifier which converts the charge into voltage. By repeating this process, the controlling circuit
converts
the entire contents of the array in the semiconductor to a sequence of voltages. In a
digital device, these voltages are then sampled, digitized, and usually stored in memory; in an
analog device (such as an analog video camera), they are processed into a
continuous analog signal
(e.g. by feeding the output of the charge amplifier into a low
-
pass filter) which is then processed
and fed out to other circuits for transmission, recording, or other processing.









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ARMS

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-
Arm

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IMAGE INTENSIFIER AND FOCAL SPOTS



Focal s
pot size is important is important in image production because a smaller focal spot produces
a clearer image. Heat intensity increases as focal spot size decreases, which could shorten the life
of the x
-
ray tube. Rotating anode tubes distribute the bombar
dment of electrons and resist pitting
a particular area. They can withstand higher heat loads produces by smaller focal spots.

Image Intensifier size refers to the diameter of the input phosphor. The typical size is 9” which is
considered normal. An Image
intensifier may also have one additional magnified view or two
magnified views.

IMAGE INTENSIFIER SIZES (INCHES) AND FOCAL SPOT SIZES (mm)

OEC 9400

BV 29

OEC 9600

ZIEHM
7000

BV 300

OEC 9800

BV
PULSERA

OEC 9900
ELITE

ZIEHM
VISION R

2010+ BV
PULSERA

9/6

12” NA

9/6

12” NA

9/6/4.5

12/9/6

9/6 OR 9

12” NA

9/6/5

12/9/7

9/6/4.5

12/9/6

9/6/5

12/9/7

9/6/4.5

12/9/6

9/6/4.5

12” NA

9/6/5

12/9/7

1.0/0.6

1.0/ 0.6

0.6/.3

1.5/0.6

0.6/0.3

0.6/0.3

0.6/0.3

0.6/0.3

0.6/0.3

0.6/0.3


Image Intensifier
-

UP or DOWN?

There are two principle means for fluoroscopy:

1.

Standard technique is x
-
ray tube down and image intensifier at top

2.

Inverted technique is image intensifier under table, or used as a table, and the x
-
ray tube is
up


DOES INVERTED TECHNIQUE REDUCE
RADIATION?


Some studies have shown that the Inverted technique significantly reduced radiation to
both the surgeon and patient. The dose rate to patient was reduced by 59% in the study
while the exposure to surgeon’s head was 67% of the measured dose with

the standard
technique. Similarly exposure to the surgeon’s body was 45% and groin was 15% of the
measures dose with the standard technique. When magnification mode of the image
intensifier was used, the doses were reduced to 46%, 32% and 11% of the stand
ard
configuration values.



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Arm

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IMAGE PROCESSING AND DISPLAY


C
-
Arm models differ extensively when it comes to the image you see on the monitors. Generally
speaking, most standard C
-
Arms have dual monitors, a feature that’s important for many
procedures. A
gradual shift from CRT inserts to LCD displays has been occurring as well as
increased density of pixel resolution. The greater the pixel count, the better the image. Some have
actually begun using color monitors, although black and white monitors are sti
ll considered better
as they produce better contrast and are brighter than color monitors.














IMAGE DISPLAY (INCHES) and IMAGE RESOLUTION

OEC 9400

BV 29

OEC 9600

ZIEHM 7000

BV 300

OEC 9800

BV PULSERA

OEC 9900
ELITE

ZIEHM
VISION R

2010+ BV
PULSERA

Dual 17

Dual 17

Dual 16
Square

Dual 17

Dual 17

Dual 16

Dual 18

Dual 19 LCD

Dual 17

Dual 18 LCD

640 x 512

512 x 512

1k x 640

512 x 512

1008 x 480

980 x 980

1008 x 576

1280 x 1024

1024 x 1024

1024 x 1024

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Arm

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X
-
RAY TUBE


The combination of power (kW), anode angle, and focal spot size dictate the use of stationary or
rotating anodes. Mobile fluoroscopic applications are sufficiently handled by a stationary anode
with 0.6mm focal spot.


However, longer Fluoro times and lar
ger daily patient volume may dictate use of a rotating anode
as it will cool faster, not get as hot during longer Fluoro, and allow for increased patient
throughput. Particularly when 0.3mm focal spot is used, a rotating anode is mandated.


X
-
RAY TUBE TY
PE

OEC 9400

BV 29

OEC 9600

ZIEHM 7000

BV 300

OEC 9800

BV
PULSERA

OEC 9900
ELITE

ZIEHM
VISION R

2010+ BV
PULSERA

ROTATING

STATIONARY

ROTATING

STATIONARY

STATIONARY

ROTATING

ROTATING

ROTATING

ROTATING

ROTATING













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-
Arm

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DEPTH OF C


The measurement from

the center beam line to the arc structure is the depth of C. It is an
important consideration for certain procedures, especially in spinal work. Many facilities and
practices are also seeing a problem with penetration of dense anatomy in larger patients
. OEC
addresses this with their Super C models which increase the depth of C significantly. Generally, the
greater the C depth, the more likely you will be able to position the C
-
Arm around obese patients.

DEPTH OF C (INCHES)

OEC 9400

BV 29

OEC 9600

ZIEHM
7000

BV 300

OEC 9800

BV
PULSERA

OEC 9900
ELITE

ZIEHM
VISION R

2010+ BV
PULSERA

23.3

23.3

26

27

24

26

24

28

27

24

NO

SUPER C

NO

SUPER C

31

SUPER C

NO

SUPER C

NO

SUPER C

31

SUPER C

NO

SUPER C

33

SUPER C

NO

SUPER C

NO

SUPER C














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-
ARMS

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-
Arm

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C
-
ARM POSITIONING


The C
-
Arm’s rotation determines to a large extent the ease with which certain procedures are
accomplished. Earlier models pre
-
date the pain management use and you may find certain views
difficult to obtain, particularly far
-
side obliqu
e imaging. If you are planning to use an older system
you need to consider the use of patient positioning aids, turning the patient during procedures, or
even the use of table with lateral tilt to make it easier.


LAO/RAO ROTATION (IN DEGREES)

OEC 9400

BV 29

OEC 9600

ZIEHM 7000

BV 300

OEC 9800

BV PULSERA

OEC 9900
ELITE

ZIEHM
VISION R

2010+ BV
PULSERA

+/
-

180

+/
-

180

+/
-

180

+/
-

225

+/
-

180

+/
-

180

+/
-

180

+/
-

180

+/
-

225

+/
-

180










CRA/CAU ANGULATION (IN DEGREES)

OEC 9400

BV 29

OEC 9600

ZIEHM 7000

BV 300

OEC 9800

BV PULSERA

OEC 9900
ELITE

ZIEHM
VISION R

2005+ BV
PULSERA

90/23

90/25

90/25

90/45

90/45

90/25

90/45

90/25

90/45

90/45






90/55

SUPER C


90/55

SUPER C



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Arm

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DOSE

REDUCTION

Pulsed Fluoro:

The
primary

purpose of pulsed Fluoro is for dose reduction. The
secondary

purpose is for reduction
of blurring while imaging moving anatomy.

The key here is that the best specs would be those that gave a wide range of pulse rate selections
-

particularly at 8
PPS

a
nd higher because this is the rate at which the image starts to appear
continuous to the naked eye. 15 and 30
PPS

rates are used to acquire cine for vascular, cardiac and
bolus chase or "runoff" applications




The Ziehm Vision R is pulse
-
based and is always in pulse mode.













PULSED FLOURO RATES (IN PPS)

OEC 9400

BV 29

OEC 9600

ZIEHM 7000

BV 300

OEC 9800

BV PULSERA

OEC 9900
ELITE

ZIEHM *
VISION R

2010+ BV
PULSERA

1, 2, 4

3,5

1, 2, 4, 8

1

3,5,8,12.5

1,2,4,8, 12

3,5,8,12.5,25

1,2,4,8

1,2,4,8,12,25

3,5,8,15,30

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ARMS

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Arm

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Typical Pricing Model for C
-
Arms


Typical hardly describes the pricing of used C
-
Arms. The reason is that C
-
Arms may be created
equal, but their previous usage and the refurbishment done on them make each one somewhat
unique. Much like used cars, what dealers do to the equipment varies.
Some may clean it, others
clean and disinfect, others refurbish and replace components. Each dealer should be able to
explain “their” brand of equipment. Terms get bandied about like patient
-
ready, refurbished,
remanufactured and each term is unique to th
e process the dealer uses.

So below we present the price variations for the models we’ve been examining, ranging from little
work done on the system to quality refurbished. Vascular units are priced a bit higher than what
you will see below

as well as sp
ecialized systems with 12” image intensifiers. Lastly,
warranty
periods, which we will discuss later,
will significantly affect
pricing
.









PULSED FLOURO RATES (IN PPS)

OEC 9400

BV 29

OEC 9600

ZIEHM 7000

BV 300

OEC 9800

BV PULSERA

OEC 9900
ELITE

ZIEHM *
VISION R

2010+ BV
PULSERA

24
-
30K

22
-
30K

35
-
42K

29
-
34K

32
-
39K

85
-
94K

60
-
72K

108
-
120K

55
-
65K

75
-
90K

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-
Arm

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GLOSSARY OF FEATURES


Collimator
:

C
-
Arms use iris collimation in combination with parallel shutter. Shutter blades can be semi
-
transparent, common in Ziehm systems where it’s argued they permit better soft tissue
visualization around long bone or spine and aids in placement of needle and s
crew alignment.
Blades can also be solid tungsten as in the OEC 9800 and OEC 9600 models or lead shutters in BV
Pulsera.

Batteries:

High
-
Voltage, sealed lead
-
acid batteries are used primarily in OEC systems only. Battery systems
should be charged overnigh
t after use. Care needs to be taken to ensure the batteries remain at full
charge or very close to full charge. A number of errors are attributed to battery issues on OEC
systems. On the other hand, the batteries provide a significant boost in power that o
ther standard
electric
-
only systems lack.

High
-
Voltage and Interconnect Cables
:

The cables connect the C
-
Arm to the Monitor cart and the camera to the image intensifier. To
enable the arc to rotate and angle, the cables are long and often drag on the flo
or or brush up
against other objects leading to cracks or breaks. With high
-
voltage running through them, it is
advisable to make sure the cables are solid with no frays or cuts.

Digital image Rotation
:

contributes to dose and time savings during surgical

procedures.

Edge enhancement
:


Improves visualization of bony edges and fracture lines digitally. All of the systems in our example
have edge enhancement.

Image Annotations
:


Labels may be added to an image for identification of anatomic structures bef
ore printing.

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Arm

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Digital Zoom:



Allows magnification of an image without needing an extra exposure at a smaller field of view.

Roam:



Once an image is magnified digitally, Roam allows the user to continuously vary the area of the
image to be magnified.

Snap
shot, One
-
Shot or DR Mode
:

A single, brief exposure is made at higher than normal mA to capture a higher quality single image.

Noise Reduction
:

All of the C
-
Arms in our example group have some noise reduction capability available. Not all
systems were orig
inally delivered with noise reduction; for most early OEC models it is an option
that came when the user ordered the Enhanced Surgical Package (ESP)

Vascular Features

Vascular
-
enabled systems have most of the features that appear below but not necessarily all. You
will see on your quote, should you request one, the individual component features of the vascular
package for the system you are interested in acquiring.

Rem
ask:


Allows the user to use a mask already used to obtain a DSA run for a Roadmap, saving time and
dose to the patient.

Pixel
-
Shift:


Allows re
-
alignment of the mask and the native image in situations where the patient may have
moved during DSA acquisiti
on. Without pixel
-
Shift, smaller vessels may be obscured by a mis
-
aligned mask.

Landmarking
:


In some situations a vascular surgeon may want to fade some of the subtracted mask away to allow
the visualization of bony landmarks in an image.

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Angle Measurem
ents
:


Often used for surgical planning in orthopedic procedures such as osteotomy. This allows the user
to “draw an angle” on a fluoro image digitally to obtain a numerical angle measurement.

Digital Cine Acquisition
:

8
-
15 FRAMES PER SECOND (FPS) is ge
nerally considered sufficient for vascular procedures. In some
cases 30 FPS may be considered favorable for neurovascular or cardiac applications. Slower
acquisition speeds may be acceptable for general surgery applications such as Laparoscopic
Cholangio
graphy or ERCP.

Digital Cine Pulse Widths
:

Shorter pulse widths stop motion blurring during dynamic vascular imaging procedures. Pulse
widths vary by anatomic program for optimal image quality.

Pulsed Fluoro with High
-
Quality Output:

Used for dynamic vascular
studies, this c
ombines High Level Fluoro & short pulses to stop motion.
High Quality mode can be used with digital cine to produce high quality bolus chase or "runoff"
studies.








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IV.

Procedure Tables


Setting up an office usuall
y means buying a procedure table as well. Here it can get quite crowded
with possibilities and costly.

For a long time, electric movement tables were very expensive


from $16,500 up to $32,500. Many
are still priced in that range. We won’t say there are n
ot worth the price, but we can say, “We
haven’t met a physician yet that wants to shell out that kind of money

for an office environment
.”


What are the reasonably
-
priced alternatives?

Most Economical is a fixed height table
. These are stationary tables with radiolucent tops,
supported by four legs with wheels (hopefully) and brakes (please). Prices range from $1,100 for a
table with no pad
and weak bolted
-
on legs
that you will hate, to $2,500 for a table with patient
comfort

pad
and welded frame
that will serve you well.

Electric Motion tables provide added ease

for the patient (as in vertical motion to lower the table
for patient entry) to lateral tilt (which will help you with far
-
side oblique views with some older C
-
Arms
that do not have sufficient rotation. There are also options for Trendelenburg (for swallow
studies) and some tables have four
-
way float tops as well (for just about any procedure).

Manufacturers of electric tables generally offer 1, 2, 3, and 4 motion tab
les. Your needs along with
your budget will dictate which is right for you. Pricing as we know it starts at around $8000 for an
electric single
-
motion table and range to $10,500 for three motion table. The float tops are typically
much higher, around $
20,0
00.







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V.

Patient Record Storage


The buzz in the industry is electronic record keeping. C
-
Arms typically store electronic records but
very few for the most part. And you have to turn on the C
-
Arm to get access to them, so they are
not the most practical ways of storing images for record

keeping purposes.

C
-
Arms can be outfitted economically with black and white printers that output a hard copy record
for your files. How much longer you will be able to use this method as an approved file storage is
waning.

Image Capture Devices provi
de the means of outputting the monitor image to the image capture
device and then move the image via USB Flash drive to a PC. These systems are very practical and
not terribly expensive, ranging from $2500 and up, depending on features.

The model that h
as the most traction in the industry is the MediCapture units.



There is a huge drive to electronic record keeping. Most C
-
Arms have some ability to hold static
images, but it’s usually not many unless the system is vascular. But as a place to store re
cords AND
retrieve them, the C
-
Arm is not the place you’ll want to keep patient records.

The recorded image, e.g., needle insertions, can be printed along with patient name, facility or
doctor name and the date by the simple inclusion of a printer. Sony i
s the market leader for these
printers. They are relatively inexpensive from $850 and can be as high as $3250 for more elaborate
models with video capabilities (vascular requirement generally).

Another solution gaining recent popularity is an add
-
on devic
e known as an image capture device.
These are plug
-
n
-
play units that can be installed by nearly anyone by connection to the BNC port on
the back of the C
-
Arm monitor cart. The advantage is of course you can save the screen image and
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port it to a computer f
or storage via a flash drive and the software that comes with it. Images can
be DICOM, JPG, BMP or TIFF.

If you plan to connect to a PACS system, you need a system with integrated DICOM which most C
-
Arms manufactured after 2008 will have, or use a “black
box” converter. The black boxes are a bit
cumbersome to install but many hospitals that have PACS have these boxes already attached to
their systems when they decide to sell.













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VI.

Radiation Protection and Safety


So, Is Fluoroscopy Really Safe?


YES
-

BUT ONLY IF the surgeon and staff follow certain steps, e.g.,



always wear lead aprons,



use thyroid shields,



use protective eye wear, and



maintain a safe distance from the radiation source
(approximately 39” minimally).

For the User/Practitioner/S
urgeon




Lead aprons, gloves and sleeved shirt/jacket should be worn by anyone working within 39
inches of the x
-
ray head



Personnel should never be in the primary beam



Patients should not be held during an exposure



Persons not directly involved in the procedure should be excluded from the procedure
room



The room should be large and there should be a radiation protective screen



Dosimeters should be worn to identify if unacceptable exposure to x
-
rays is occurring

Fo
r the Patient



Use the fastest combination possible to obtain pictures



Collimate the primary beam to include only the area of interest



Use a reasonable film
-
focal distance



Avoid repeat exposures


For the Public



While the beam scatter is minimal on a C
-
Arm, check local regulations to determine
shielding requirements for the treatment room



Warning lights should be placed outside the procedure room to signal preparation and
exposure



Radiation warning signs should
be present on doors leading to the procedure room



People under 16 and pregnant women should not be allowed to assist in procedures.



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Radiation protection equipment



Aprons



Gonad Shields



Thyroid Shields



Table Drapes



Eyeglasses or Goggles

CDC Recommendatio
ns


Recent investigations undertaken by state and local health departments and the Centers for
Disease Control and Prevention (CDC) have identified improper use of syringes, needles, and
medication vials during routine healthcare procedures, such as admini
stering injections. These
practices have resulted in one or more of the following:



Transmission of
blood borne

viruses, including hepatitis C virus to patients



Notification of thousands of patients of possible exposure to
blood borne

pathogens and
recomm
endation that they be tested for HCV, HBV, and HIV



Referral of providers to licensing boards for disciplinary action



Malpractice suits filed by patients

These unfortunate events serve as a reminder of the serious consequences of failure to maintain
stri
ct adherence to safe injection practices during patient care. Injection safety and other basic
infection control practices are central to patient safety. All healthcare providers are urged to
carefully review their infection control practices and the pract
ices of all staff under their
supervision. In particular, providers should ensure that staff:



Never administer medications from the same syringe to more than one patient, even if the
needle is changed



Do not enter a vial with a used syringe or needle

Hepatitis C virus, hepatitis B virus, and HIV can be spread from patient to patient when these simple
precautions are not followed. Additional protection is offered when medication vials can be
dedicated to a single patient. It is important that:



Medicatio
ns packaged as single
-
use vials never be used for more than one patient



Medications packaged as multi
-
use vials be assigned to a single patient whenever possible



Bags or bottles of intravenous solution not be used as a common source of supply for more
th
an one patient



Absolute adherence to proper infection control practices be maintained during the
preparation and administration of injected medications




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VII.

Warranty


Warranties are the dealer’s stamp of confidence in the product. There are several flavors
of
warranties out there ranging from none (as
-
is), 30 days, 90 days, six months to one year. (If
someone offers more than one year


run the other way as they are not likely to still be in business
when you need them.)

Warranty can cover parts only, labor

only, parts and labor. Some include glassware (x
-
ray tube,
image intensifier and TV camera which happen to be the most expensive replacement items. Some
dealers offer “comprehensive” warranties but prorate the glassware coverage. Some (most) do not
cover
glassware at all.

To be honest, we’re not saying that a dealer who doesn’t offer glassware coverage means that the
system they offer to sell is necessary any more likely to have trouble with one of the three
components. Rather, it comes down to a rick man
agement decision. By not taking the risk and
passing it along to you, they can offer a lower price. (I hope you didn’t think they were selling it to
you for less simply because they liked you; sorry.)

How important is your peace of mind? As lawyers like to

say, how much do you value the quiet
enjoyment of the system?













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VIII.

Payment Options


If you
are not buying with outright cash, ther
e are two alternatives from which you can choose.
What's the difference?


LEASE:

When you lease, the lease company
is the actual buyer/owner of the
equipment while you are renting it. You will have the option to buy it at
lease end for $1.00 or FMV. During the lease, you can deduct the lease
payments as an expense of doing business.


FINANCE:

When you finance, you are
the buyer/owner of the equipment and you
are entitled to depreciation and interest deductions for income tax
purposes.


PLEASE NOTE: It is always advisable to consult with your accountant as to which form of purchase is
best for your current financial sit
uation.












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IX.

Delivery, Set
-
Up and First Use


TRAINING

Companies selling refurbished systems provide one of the following training services:

1.

Full feature training, how to use all the functions, how to move images from screen to
screen, how to save in

memory or to storage device, how to enter the patient data, and
how to print pictures for record keeping.

(This is what C
-
ArmsUSA provides)

2.

Outside training from a third party service company which can be thorough but in the odd
event (and odd things do
frequently occur with C
-
Arms) something fails during the training
session, you will find yourself in the middle of a finger pointing session of who is
responsible for getting it up and running.

3.

Limited training, how to connect the C
-
Arm, turn it on.

(Ther
e's one company that has it's truck driver train you)

4.

Stop, drop and run.



PHYSICIST INSPECTION

Please note well, most states require that your C
-
Arm be certified to be in compliance with
radiation emitting standards set by the federal government. It is
your responsibility to have this
certification completed prior to first patient use and each subsequent anniversary year that you
own the machine.









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X.

Re
furbished or Not?


We’ve purposefully saved this chapter for the end. It’s possible to discuss thi
s topic for pages and
pages, debating refurbished, remanufactured, patient
-
ready and a myriad of other descriptions
dealers use to describe a used C
-
Arm.

Let's start with this:
there is no standard definition or process to describe refurbishment.

When
you hear, “We refurbish,” or “We remanufacture,” or “We completely rebuild,” you are hearing
the
same thing just sales
-
puffery
.

Our equipment is remanufactured

So, we just don't buy this one. How can you put used parts in a used system and call it
r
emanufactured? For most of the used systems, OEMs stopped making parts long ago.

Our equipment is remanufactured to OEM standards

Again that word remanufactured. And how did they get OEM standards? Espionage?

Our equipment is refurbished and reconditione
d

Talk about overkill. You do both?

Our equipment is made to conform to exacting standards

What exacting standards are we exactly talking about? There really aren’t any exacting standards.

In summary, there are a lot of companies selling refurbished C
-
Arm and they use various definitions
of refurbished, used, remanufactured and on and on and it’s very confusing but in the end you
decide to buy only on price and you end up with a very bad exp
erience.

How can you avoid this? It would be wonderful if the industry published a blue
-
book pricing like the
auto industry. It hasn’t been done.
guide





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XI.

Return on Investment (ROI)


We’ve pretty much covered everything. If you’ve followed chapter by ch
apter, and have ideas of
solutions for each section, then you can put together a Return on Investment Analysis. The form
below will help you with those calculations.



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E Q U I P M E N T I N V E S T M E N T A N A L Y S I S












OEC 9600


Your Investment






Amount You plan to spend on C
-
Arm





39,900.00











Amount you plan to spend on a Table





9,500.00











Total Investment under consideration





49,400.00











Your Expenses






Enter the Dimensions of your C
-
Arm procedure room


12.00


X

15.00











Enter your annual rent per square foot





31.00











Annual Cost of assistants used during C
-
Arm procedures





25,000.00











Typical or Average Reimbursement rate for procedures (national avg = $322)





275.00











Average percentage of
reimbursements actually collected
(nat. avg = 90%)







90%











Anticipated number of procedures per week





15.00











Cost of incidentals per exam (nat. avg = $3.95)





4.25




















Summary of Income and Expenses















Total Revenue from procedures








214,500.00











Less uncollected
reimbursements








(21,450.00)











Net Revenue








193,050.00











Equipment Cost








49,400.00











Rent, Personnel, Incidentals Allocated

C
-
Arm Room Annually








33,895.00














Profit per Exam






270.75


































Your Return on Investment (ROI)









Your total period for Payback is:






4.73


months

















Your Breakeven point is:






308


exams



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If you’ve done the ROI analysis in the last chapter, you can get an idea of how long you’ll need to
keep the system to breakeven and at what point you begin to profit from having a C
-
Arm procedure
room.

For a typical pain management practice or infertilit
y clinic, a standard C
-
Arm will pay for itself
quickly and enrich the practice immeasurably.