When should a biplane c-arm (c-arm fluoroscopy system) be used instead of a single c-arm in medical procedures?

Biplane vs Single C-arm Fluoroscopy: Clinical Indications

Primary Recommendation

Biplane fluoroscopy is essential and should be used for transseptal atrial puncture procedures, particularly in small patients, and is strongly recommended for complex cardiac catheterization procedures requiring simultaneous orthogonal views. 1, 2

Specific Clinical Indications for Biplane C-arm

Transseptal Puncture (Mandatory)

• Biplane fluoroscopy is essential for safe and dependable performance of transseptal atrial puncture, particularly in small patients, allowing constant 3-dimensional mental reconstruction of intracardiac structures that provides depth and simultaneous side-to-side relationships within the heart during the puncture. 1, 2
• Single-plane fluoroscopy should only be considered under extenuating circumstances, and only for operators with thorough knowledge of atrial septal anatomy and extensive experience with the transseptal technique. 1
• Single-plane systems are contraindicated in very small patients, patients with very large or very small left atrium, large dilated aortic root, no inferior vena cava access to the atrial septum, or any abnormal cardiac chamber/great vessel positional abnormalities. 1, 2

Complex Congenital Heart Procedures

• Biplane fluoroscopy is essential for accessing critical locations in the pulmonary venous circulation after complex congenital heart surgical repairs (Mustard/Senning procedures, lateral tunnel Fontan procedures). 1
• The technique allows safe transseptal puncture through surgical baffles where anatomic landmarks are distorted. 1

Cardiac Catheterization Laboratory Setup

• For biplane cardiac catheterization systems, overhead support of the lateral imaging system facilitates patient access and is recommended by ACC/AHA guidelines. 1
• When filming in biplane mode, cinecameras should operate out of phase to avoid exposure overlap, reduce scatter, and improve image quality. 1

Single C-arm Applications

General Surgical and Orthopedic Procedures

• Single mobile C-arms are appropriate for routine orthopedic procedures, trauma surgery, and general fluoroscopic guidance where simultaneous orthogonal views are not required. 3, 4
• Modern flat panel detector C-arms can achieve equivalent or better image quality at significantly lower radiation doses compared to older systems. 3

Percutaneous Lung Biopsy

• For percutaneous transthoracic lung biopsy, C-arm screening (or biplane if available) with vertical or horizontal needle insertion provides optimal results. 1
• Single-plane fluoroscopy is acceptable for larger lesions visualized on posteroanterior and lateral chest radiographs. 1

Important Caveats

Radiation Exposure Considerations

• Operator radiation exposure is somewhat greater with C-arm devices, requiring x-ray-dense glass shields positioned between the x-ray tube and operator. 1
• The correct choice of mobile C-arm technology can reduce intraoperative radiation dose without negative effects on image quality, benefiting both patients and OR personnel. 3

Equipment Specifications

• Image intensifiers with diameter greater than 9 inches are not recommended for cardiac catheterization because size interferes with obtaining steep sagittal angulation (>42°). 1
• Equipment should allow easy positioning for all single and biplane views with patient support accommodating at least 300 lb. 1

Emerging Applications

Advanced Thoracic Procedures

• Biplane fluoroscopy in hybrid operating rooms provides superior image quality compared to standard C-arm fluoroscopy, particularly useful for upper and mid-thoracic percutaneous screw placement where shoulder anatomy limits lateral visualization. 5
• This represents an underutilized function of biplane hybrid ORs that enhances safety and visualization. 5