Summary: 3D printing is making rapid advances in many areas of medical treatment. In this article, I'll describe how I used recent advances in 3D printing to save a patient from having to have her spleen removed. In the process I broke some new ground in use of 3D printing in surgical planning. The clinical case and 3D printing advances are described in a recently published peer-reviewed paper in the medical journal Diagnostic and Interventional Radiology.
Intro image: The author using 3D printed vascular models in the OR.
A clinical conundrum
I am a board-certified interventional radiologist, and specialize in the minimally-invasive treatment of vascular (involving blood vessels) disorders. My adventure in 3D printing started when a very nice 62-year-old lady was referred to me by another doctor. A CT scan done for another reason had incidentally detected aneurysms in her splenic artery. The splenic artery is the major artery going to the spleen. An aneurysm is a bulging of the artery wall. Aneurysms are dangerous because as they grow they stretch the artery wall, causing it to thin. Like a balloon, the more the aneurysm stretches, the thinner the artery wall becomes, until the wall is too thin to hold back the pressure of the blood and the aneurysm bursts. This can lead to sudden, acute, life-threatening internal bleeding.
Figure 1. Examples of aneurysms. The thin, stretched out walls of the aneurysm predispose it to rupture. The larger the aneurysm, the greater the risk of rupture and bleeding. Source Drugline.org.
Medical convention states that when a splenic artery aneurysm is 2 cm or larger, it is at risk for rupture and should be treated. My patient had two aneurysms in her splenic artery, each of which was 2 cm in size. Something needed to be done. A third, smaller aneurysm was also present but it didn't need to be treated at this time. The conventional treatment in this situation is a surgical splenectomy, in which a surgeon, either in an open fashion or laparoscopically, physically removes the splenic artery with its aneurysms. Because the spleen cannot survive without its artery, it must be taken out too. The spleen plays a critical role in the body's ability to fight infections, so after removal of the spleen, patients are at higher risk for certain infections.
Video 1. Digital rendering showing the two large splenic artery aneurysms arising from the splenic artery. The aneurysm are the sphere-like bulges arising from a small artery in the middle of the aorta. The large trunk is the abdominal aorta. Rendering done with Blender.
An alternative treatment to surgical removal is splenic artery embolization. In this procedure, a vascular surgeon or interventional radiologist, such as myself, will make a needle puncture in the artery of the hip and navigate a small plastic tube, called a catheter, into the splenic artery using x-ray guidance. A series of small metallic threads, called coils because they coil up once deployed, are then pushed through the catheter into the splenic artery, where they plug up the entire artery. In principle, the technique is similar to putting hair down your bathroom drain. The hair takes up space and eventually plugs the pipe. In the same way, fine thread-like platinum coils can be pushed into the artery one at a time until the artery is plugged up. Any blood in the artery clots, and without any blood flow there is no pressure on the aneurysm wall and thus no risk of the aneurysms rupturing. Unfortunately, the lack of blood flow also causes the spleen to die from insufficient oxygen. The process of the spleen dying from lack of blood flow results in pain for a day or two. Also, without a functional spleen, these patients also are at higher risk for infections.
My patient was a very intelligent and determined individual. I explained both options to her in detail, but she would not accept either of the conventional treatments. She did not want to lose her spleen and be at increased risk of future infections. She challenged me to find a way to treat her aneurysms while saving her spleen. I reviewed the case and imaging studies with several of my colleagues, all board-certified specialists in treating this type of problem. Everybody said the spleen couldn't be saved. It was "impossible." She either had to have her spleen removed or her splenic artery embolized. Do nothing and it was just a matter of time until an aneurysm ruptured, probably killing her. I was greatly moved by my patient's doggedness. She wasn't willing to accept the limits of conventional medical treatment, so I didn't think I should either. I kept searching for solutions.
I was aware of some specialized catheter equipment that had been specifically designed to treat aneurysms in the brain. Brain aneurysm treatments are very delicate affairs. If an aneurysm in the brain ruptures, it can result in intracranial bleeding, stroke, permanent disability, or death. Brain aneurysms can be treated with placement of metallic coils through a catheter, as long as the coils are only placed in the bulging, aneurysmal part of the artery. There, they cause blood to clot in the aneurysm, which reduces pressure on the aneurysm wall and prevents it from rupturing. These special coils and catheters are designed to treat the aneurysm while preserving blood flow in the parent artery. Because these aneurysms are in the brain, any disruption in the blood flow of the parent artery will result in stroke.
Figure 2: How coils can be used to treat aneurysms in the brain. Using specialized equipment designed for the brain, coils are used to pack the aneurysm while preserving blood flow in the parent artery. (Image source: wix.com)
Could the specialized coils and catheters designed to treat aneurysms in the brain work in the splenic artery? Nobody seemed to know. The patient's splenic artery had an unusually large number of loops, which would complicate any procedure. A search of the published medical literature did not produce any useful results. There were many variables that were different. I discussed my thoughts with the patient. I thought there might be a way to treat her aneurysms while sparing her spleen using this specialized brain aneurysm equipment. But the only way to know if the equipment would work would be to try it during an actual procedure. She gave me a puzzled look. "Well isn't there a way for you to practice?," she said.
For generations doctors faced with difficult and complex surgical procedures have really had only one true way to know if they will work: try it in a real surgery. We do everything possible to maximize our chance of success, such as ordering scans, consulting colleagues, reading research articles, and imagining the procedure over and over again in our heads. We try to know everything possible about the intended surgical procedure beforehand. But, the only way to truly know how things will go is to actually do it. There really wasn't any way to know how the brain catheter equipment would work in the spleen because nobody had ever done a procedure quite like this before. Yet, I kept thinking about my patient's statement. Why wasn't there a way for me to practice this beforehand?
Finding a solution with 3D printing
At that point I had been looking into uses for 3D printing in medicine for about a year. There seemed to be great potential, but at the time few people were using 3D printing in real patient care. I had designed a few simple 3D printable body parts from medical imaging scans. Would it be possible to 3D print a replica of my patient's splenic artery, and practice doing this complex procedure in the 3D printed model? I had never 3D printed an arterial structure of such complexity. Another search of the medical literature revealed that nobody else had either. I was further hampered by the fact that as a private practice doctor, I don't have access to an expensive 3D printer or the costly proprietary software that is needed to create complex 3D printable anatomic models. Nobody was paying me for my time or expenses. I needed to find a solution that was practical but inexpensive.
I invested hundreds of hours testing free and open source software packages to see if they could be used to generate the detailed 3D printed splenic artery model I needed. I eventually found that a combination of the software packages Osirix and Blender, the latter of which is typically used for computer animation, would allow me to design a detailed anatomic model from my patient's CT scan. I could then use the low-cost online 3D printing services Shapeways and iMaterialise to actually print my models. I paid for everything out-of-pocket. When the models arrived in the mail I couldn't believe it. They were precise full-scale replicas of the patient's splenic artery.
Figure 3: A precise 3D printed replica of the patient's splenic artery.
I contacted representatives from the companies that manufactured the brain aneurysm equipment. They had never heard of anybody testing their equipment in a 3D printed model before, but enthusiastically supported it. They donated real guidewires, catheters, stents, and coils for use in testing. Several came over to my house and we replicated the entire procedure inside the 3D model. During this testing I learned that some of catheters and wires would work well in the complex curves of the patient's splenic artery, and others would not. I was able to get all of the trial and error done in the model, something that otherwise would have taken place during the actual procedure. The model wasn't exactly the same as a real patient, but I was able to learn a lot about how the catheters and wires handled in the complex and unique geometry of the patient's splenic artery.
Video 2: Time-lapse footage of endovascular wire and catheter testing in the 3D printed model. Numerous problems were encountered with the difficult geometry of the splenic artery, but with trial-and-error a combination of wires and catheters was found that could handle the difficult geometry.
With the optimal set of catheters, wires, stents, and coils preselected, I subsequently did the real procedure on the patient. I completed all the necessary paperwork including getting approval from my hospital's research review board. I brought the 3D models into the operating room as a reference, and referred to them many times during the procedure. All of the preselected equipment worked beautifully, just as it had in testing. I was successful in putting coils in the aneurysms while preserving blood flow to the spleen. Even without having to try out different equipment combinations, the procedure was still very difficult and took five hours. If I hadn't had the ability to practice the procedure in the 3D printed model and preselect my equipment, it easily could have taken twice as long. That is, assuming I didn't collapse from exhaustion and dehydration before finishing it. More importantly, the opportunity to practice the procedure beforehand gave me confidence that I could be safe and successful in doing something that had never been done before. Nearly 2 years after the surgery, the aneurysms no longer a threat and the patient's spleen is fully functioning.
Figure 4: Referring to the 3D printed models in the OR during the surgical procedure to correct the splenic artery aneurysms.
Figure 5: positioning a small catheter into the splenic artery via a needle puncture in the arm.
3D Printing Lessons Learned
This experience fundamentally changed my perception about the value of 3D printing in medicine. For safe, easy, and routine medical procedures, 3D printing will probably not have much of an impact in the foreseeable future. It's too time consuming and costly to make 3D printed models. For complicated or high risk procedures, however, it can be invaluable. No doctor wants to take unnecessary risks or have a bad outcome in surgery. Unfortunately, there are many, many unknowns in surgery, particularly with complex and unusual cases. 3D printing an anatomic model before surgery to study and practice reduces those unknown variables, making risky cases much safer. After my experience, I have no doubt that 3D printing will have a significant impact in improving patient care in all fields of medicine.
It is my belief in the potential of 3D printing to help doctors and patients that led me to the creation of this website, Embodi3D.com. Embodi3D is a place where 3D printing enthusiasts can help each other in all fields of biomedical sciences. Members can read medical 3D printing news, ask technical questions in the forums, and even download complete 3D printable medical models from the File Vault. There are several tutorials on how to start 3D printing medical models yourself. Everything on the website is free. I ask only that you give back to the community through comments, advice, and sharing of 3D models, if you are able.
Below are two 3D printable models used in actual testing. You can download the models yourself for free.
Download the FREE solid, splenic artery aneurysm lumen model. This is the solid model that shows the hollow space inside the artery (the lumen).
Download the FREE hollow splenic artery aneurysm model. This is the hollow model that the catheters and wires were tested in.
You can read the official peer-reviewed account of this 3D printing advance in the medical research journal Diagnostic and Interventional Radiology here.
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