Very economical immersion pump feasibility for postmortem CT angiography [PREPRINT]

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Very economical immersion pump feasibility for postmortem CT angiography [PREPRINT] Article  in  Journal of Forensic Radiology and Imaging · June 2016 DOI: 10.1016/j.jofri.2015.11.009

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Very Economical Immersion Pump Feasibility for Post Mortem CT Angiography Wolf Schweitzera , Patricia Mildred Flacha , Michael Thalia , Patrick Laberkea , Dominic Gaschoa a

Department of Forensic Medicine and Imaging, Zurich Institute of Forensic Medicine, Universit¨ at Z¨ urich, Z¨ urich, Switzerland

Abstract Background: Current post mortem CT angiography (PMCTA) methods lack machines that are low priced and openly accessible. The aim of this technical study was to evaluate the usage of a very economical mobile immersion pump in comparison to a standard roller pump of a heart-lung machine for PMCTA. Methods: A Barwig Model 0444 immersion pump and a roller pump mounted inside a conventional clinically certified St¨ ockert Shiley heart-lung machine were used. Contrast agent (water soluble contrast agent dissolved in PEG 200 at 1:20) and PMCTA parameters were same across both methods. Two PMCTA full body scans of a comparable post mortem interval are compared. Results: Calibrating voltage against flow rate yields a linear relationship for both water and PEG based contrast solution. Imaging yields similar results for both pump methods. Conclusions: A more widespread and systematic implementation of PMCTA needs the premise of affordable equipment for facilities with tight budgets. Evaluation of an economical pump system is a step into that direction. This study shows that for specific post mortem application, a very low priced immersion pump delivers equal results to a clinically certified costly roller pump.

Keywords: Post mortem CT angiography, PMCTA, low cost, immersion pump, Virtopsy, forensic pathology Publication reference This is a presubmission draft (final paper: [1]), however with image quality exceeding that of publisher (Elsevier).

Published: http://www.sciencedirect.com/science/article/pii/S2212478015300320 Wolf Schweitzer, Patricia Flach, Michael Thali, Patrick Laberke, and Dominic Gascho. Very Economical Immersion Pump Feasibility for Post Mortem CT Angiography. Journal of Forensic Radiology and Imaging, 2015

BibTeX entry: @article{schweitzer2015submjofri, title={Very Economical Immersion Pump Feasibility for Post Mortem CT Angiography}, author={Schweitzer, Wolf and Flach, Patricia and Thali, Michael and Laberke, Patrick and Gascho,Dominic}, journal={Journal of Forensic Radiology and Imaging}, year={2015}, publisher={Elsevier} }

Email addresses: [email protected] (Wolf Schweitzer), [email protected] (Patricia Mildred Flach), [email protected] (Michael Thali), [email protected] (Patrick Laberke), [email protected] (Dominic Gascho) Preprint submitted to Journal of Forensic Radiology and Imaging

May 1, 2018

1. Background Ten years ago, post mortem computed tomography (PMCT) in forensic medicine gained the addition of post mortem computed tomography angiography (PMCTA), initiated by a ground breaking paper by Jackowski et al. [2]. Post mortem angiography is not obvious due to arrested blood circulation and subsequent post mortem changes. First works on PMCTA focused on contrast agents [2, 3] but not so much on the method used for contrast medium circulation. Since then, post mortem angiography has become increasingly popular both for research and case investigation. Grabherr et al. introduced diesel oil based contrast agent solutions into PMCTA in 2006 [3]. Subsequently, Grabherr co-authored a number of post mortem angiography patents (2009 [4], 2010 [5], 2012 [6] and 2013 R and a dedicated pump termed [7]). The oil-based contrast agent branded Angiofil R [8] were then made commercially available through collaborative efforts Virtangio R while a working group1 was spearheaded, employing that particular with Fumedica , choice of devices and materials as a de facto-standard also through a series of publications [10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21]. This is an impressive coordinative aspect while one has to acknowledge that academic authors that hold patent applications or commercial licenses are more productive generally [22]. With that, the current leading commercial solution for post mortem angiography has R to be regarded to be the Virtangio machine that is sold in conjunction with the R R oil-based patented contrast agent Angiofil [4, 5, 6, 7, 23]. The Virtangio machine costs up to around 80’000 CHF, and a single post mortem scan costs an added amount of around 500 CHF (consumables including contrast agent and tubes). Such costs are R prohibitively high for many forensic pathologists. The Virtangio machine offers relatively convenient handling and controls, and at its core, it contains a roller pump. The choice of a particular pump system is a technical issue and therefore warrants technical considerations. Why PMCTA started out specifically using roller pumps is not clear [2, 3, 24]. Heart-lung machines [25] contain relatively costly peristaltic or roller pumps [26] also to preserve the integrity of corpuscular blood components [27]. Roller pumps excel in transporting fluids with non-Newtonian characteristics (i.e., non-constant viscosity such as blood, more generally containing emulsions, suspensions, slurries; illustrative examples are ketchup or paint) o. Post mortem angiography requires homogenous watery or oily solutions to be quite simply pumped from a container into the body of a deceased person. More cost-effective and therefore ideal PMCTA pumps may better be inspired by typical oil or water pumps, so we chose a simple centrifugal pump with a small paddle wheel. Administration of contrast agent solution in PMCTA seems to require a specific flowrate. Ross et al. published a comparison of contrast agents [24], where he described perfusion volumes of about 2000mL for head, neck, thorax, abdomen and the upper extremities and about 400mL for the lower extremities; he used a 1 Technical Working Group Postmortem Angiography Methods (TWGPAM): its website lists Lausanne (Switzerland), Hamburg (Germany), Munich (Germany), Toulouse (France), Foggia (Italy), Krakow (Poland), Leicester (Great Britain), Basel (Switzerland) and Leipzig (Germany) (in the order cited [9]).

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decommissioned pressure controlled heart-lung machine (HL20, Maquet) with a perfusion pressure of around 80mmHg. Morgan et al. ([30], following [12]) reported R an Angiofil flow rate of 800mL/Min and a volume of 1200mL (arterial) and 1800mL (venous) before adding 500mL @ 200mL/min for the ”dynamic” phase. Contrast agent solutions such as polyethylene glycol (PEG) substrates exhibit concentration dependent viscosity [31]. Roberts et al. [32] report a flow rate of 10mL/sec (600mL/min). So from literature, one may assume that approximate flow rates somewhere between 200mL/min and 800mL/min should result in acceptable organ perfusion. Based on the expectation that any centrifugal pump mustering a flow rate of watery or oily fluids as low as 1L/min would suffice for sufficient vascular filling, we invested into a relatively powerful pump ceiling at a 10L/min flow rate. As this first feasibility test result exceeded our expectations, this technical note thus describes the first use of this very affordable immersion pump (Fig. 1), effectively achieving immersion pump PMCTA (IP PMCTA, in full nomenclature accordance [33]) that results in data that is equivalent to PMCTA performed with a standard heart-lung-machine (HLM PMCTA) (Fig. 2, 3 and 4). The aim of this technical study was to evaluate PMCTA using a very economical mobile immersion pump in comparison to a standard roller pump of a heart-lung machine. We show a side by side comparison of first results.

2. Methods 2.1. PMCTA: vascular access, contrast medium, PEG Water soluble contrast agent and polyethylene glycol (PEG) were used as this has been found to provide a superior quality in post mortem angiographic visualization compared to an oil based approach [24]. Vessels were catheterized at the level of subinguinal femoral vessels by an autopsy technician (Cannula PU 14F 100mm, Sorin Group International SA, Lausanne, Switzerland; 1/4–1/4 straight connector). A water-soluble contrast medium (Optiray 300, Guerbet, Paris, France) was diluted in PEG (PEG 200, Schaerer and Schlaepfer, Rothrist, Switzerland) with a ratio of about 1:20 to achieve a mean density of around 350 Hounsfield units (HU) (calibrated via CT scan of the contrast media mixture) and injected in the arterial vascular system only, using two different pumps: an immersion pump, and a heart-lung machine.

2.2. Specification of immersion pump We used an immersion pump (12-24V, Model 0444 max. 600L/h ∼ 10L/min, 145g, 30 x 80 mm, 0,9-1,7A, 40W, Barwig Wasserversorgung, D-34385 Bad Karlshafen; cost around 16 to 20 CHF) that we controlled by a variable DC power supply (0-30V, 0-5A, power consumption 230 V/AC +/- 10% @ 50 Hz, weight 4,95 kg, +5 to +40 deg Celsius operating temperature, Basetech BT-305, Basetech, Conrad Electronic SE, D-92240 Hirschau; cost 130 CHF). The pump is constructed to be safely operated in a submerged position. It is approved for pumping drinking water. Its motor is sealed, it features service free lifetime lubrication also for maintenance free dry runs. Due to the build of the pump, maximal cycle times of 30 minutes are permissible but for continuous operation in

3

A

B

i f

s m

o

c power supply

1cm

o

c

C

*access

power supply pump pump

DE

Figure 1: Immersion pump set up for usage in post mortem CT angiography. The pump (A, B: CT of the pump, view on front facing longitudinal virtual cut surface with inflow (i), outflow and conical tube connector (o), cable (c), motor (m), shaft (s) and paddle wheel (f)) is immersed in the contrast agent solution that we placed into a plastic container (shown in D and E). The pump draws electricity from a voltage controllable power supply (control panel in C; whole device in D, E). Display of the entire setup (E), a PVC tube connects the pump that is immersed inside the contrast agent container to the femoral region (*access) of the deceased positioned on the table of the post mortem CT.

excess of 30 minutes, voltages not higher than 9V DC should be applied. Approved operating temperatures are between 0 and 50 degrees Celsius. The pump is sold and delivered with an electric cable sealed inside and exiting the pump. The outlet contains a conical extension that we used to heat shrink a polyvinyl-chloride (PVC) tube onto it.

2.2.1. Flow rate and voltage calibration Positive displacement pumps such as roller pumps are characterized by a flow rate that is fairly unresponsive to variation of fluid viscosity; conversely, centrifugal pumps such as the very low cost model we employed exhibit lower flow rates with higher viscosity with the same voltage. For that we employed a scaled container and a manually operated stop watch. A total of 35 measurements were obtained for both (less viscous) water and (more viscous) contrast agent PEG solution. Linear regression was performed using statistics software (JMP 11, SAS, Cary NC, USA) (Fig. 5).

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2.2.2. Handling Cleaning is performed by immersion into detergent and subsequent pumping (Fig. 6). The pump is very small and light, which reflects on the overall handling (details in Table 1). The immersion pump including extras can easily be fit into a suitcase or bag, and thus is mobile. One-handed manipulation risks to spill watery PEG solution onto the floor, which may be hazardous due to slipperiness, as a first practical test of this tiny pump revealed; bi-manual manipulation of tubing and pump is thus strongly advised.

2.3. Specification of heart-lung machine As comparison, we used a standard St¨ockert Shiley heart-lung machine with four multiflow roller pumps, one of which was used for post mortem angiography (max. 10L/min, 4 x 80W, 25 kg, 29 x 19 x 47 cm). Such a second hand device currently has an estimated street price of around 1500 CHF [34].

2.3.1. Handling While we used a typical clinically certified decommissioned heart-lung machine that contains a sturdy build, its 25 kg require that the pump is mounted on a wheely frame. Considerable storage space is required.

2.4. PMCT and PMCTA scanning details PMCT and PMCTA were both obtained on a dual-energy CT scanner (Somatom Flash Definition, Siemens, Forchheim, Germany). PMCT scan parameters as published [35]: tube voltage 100 kVp, automatic dose modulation software (CARE dose 4D, Siemens, Forchheim, Germany), slice thickness 1.0 mm, increment 0.6 mm, image reconstruction with both soft tissue and bone kernels. Image read-out and volume rendering technique (VRT) imagery (Fig. 3 and 4) were obtained with R standard workstation software using factory preset settings (Syngo .via, Version VA30A, Siemens, Medical Solutions, Erlangen, Germany) on standard commercial hardware. Features Cost of hardware

Weight Size

Max. flow rate

Barwig immersion pump

St¨ ockert Shiley roller pump

∼200 CHF brand new, incl. power supply, plugs, tubing, etc. 0,145kg +5kg power supply can be transported with a bag storage can be shelf space 10L/min

∼1’500 CHF used / refurbished

Table 1: Device feature comparison.

5

25kg big, transport requires van storage requires room space 10L/min

IP PMCTA b

a

c

1

IP PMCTA g

HLM PMCTA b’ a’

c’

HLM PMCTA g’

4 h’

h e

d

d’

e’

2

5 i

f’ f f

i’ j

j’

f’

3

6

Figure 2: Comparing the new very affordable immersion pump PMCTA (IP PMCTA) and conventional heart-lung machine PMCTA (HLM PMCTA), we find comparable quality in the cheaply afforded scans in an axial side by side image comparison. Both carotid arteries (a/b and a’/b’) are equally well shown as the basilar artery (c/c’). The Circle of Willis exhibits equally distinct filling of the arteries (d/d’, e/e’) despite the presence of a vessel leak in the IP PMCTA case (ruptured aneurysm, subarachnoid hemorrhage already present at native PMCT prior to PMCTA). Subcutaneous arteries at the temple similar (f/f’). The left circumflex coronary artery (g/g’) and the left anterior descending coronary artery (h/h’) are depicted clearly in both techniques. Side by side of pelvic arteries (external(i/i’) and internal (j/j’) iliac arteries) with similar delineation.

2.5. Cases Examined with IP PMCTA: 47 year old male, death scene examination around 2-5 hours after death, cooled storage of the body for about 21/2 days before PMCT, PMCTA and autopsy. Cause of death was a ruptured aneurysm as cause of a subarachnoid hemorrhage. Examined with HLM PMCTA: 52 year old male, death scene examination around 1 day after death, cooled storage of the body for about 21/2 days before PMCT, PMCTA and autopsy. Cause of death was attributed to an aortic dissection (not ruptured). Both cases were scanned as part of our standard procedure when examining cause and manner of death. Examinations were performed under an agreement with the prosecutor’s office, and PMCTA indications were part of the routine evaluation for both cases. Research publication was authorized by the ethics committee of the

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HLM PMCTA

IP PMCTA

Figure 3: Immersion pump PMCTA (IP PMCTA) contains similarly clearly reconstructed temporal and occipital arteries (arrows) in this VRT side-by-side display as the PMCTA performed with a conventional heart lung machine (HLM PMCTA).

Canton of Z¨ urich, Switzerland (KEK number: 30-2015).

3. Results 3.1. IP PMCTA This immersion pump’s flow rate is determined by both fluid viscosity and voltage. A mostly linear flow rate to voltage relation resulted from calibration (Fig. 5). Flow rate was effectively controlled with the voltage knob of the power supply. There was no pressure measurement in place, but visual checks of the femoral access revealed no leakage, and continuous reduction of the container content was observed during contrast agent administration. Firstly the PEG contrast agent solution into the body for half a minute at a pump voltage of 3V, then turned up to 5V and left it there for about 5 minutes (yielding an approximate flow rate of 250mL/min). When the container showed that around 2500mL had been injected into the arterial system, the pump was stopped.

3.2. HLM PMCTA Standard protocol using a flow rate of around 0,8L/min using a total of about 2500mL of PEG contrast agent solution was applied.

3.3. Imaging The methods IP PMCTA and HLM PMCTA yielded similar results when comparing images (Fig. 2, 3 and 4).

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HLM PMCTA

IP PMCTA

d

c

c’

e

a b

a’

f

e’

b’

g

d’

f’

g’

Figure 4: Vascular imaging using volume rendering of whole body reconstructions (magnified and omitting most of the legs) yield comparable results for both the immersion pump (IP PMCTA)and the conventional heart lung machine (HLM PMCTA) systems. The arm arteries (a/a’) are displayed into the periphery (b/b’); carotid arteries (c/c’, d/d’) as well as abdominal arteries (e/e’), kidneys (f/f’) and lower extremities (g/g’) are featured equally well.

IP PMCTA revealed a leak in the vicinity of a subarachnoid hemorrhage that was already there at PMCT prior to PMCTA. Autopsy showed a ruptured aneurysm as cause of the subarachnoid hemorrhage, thus explaining the contrast agent leak. Thus, no unexpected extravasation occurred.

4. Discussion We showed that for post mortem CT angiography (PMCTA), results equivalent to what is achieved with a peristaltic roller pump are generated using a very low cost immersion pump. The reason for that is technical: the particular pumped liquid in this instance is adequately transported using a properly used centrifugal pump. Generally, PMCTA is interesting for forensic pathologists. Current PMCTA applications with particularly useful results appeared to be trauma cases, natural death [36], decomposed bodies [37] as well as selected vascular access (SVA) in context of PMCTA which one might consequentially term SVAPMCTA [32, 38] and now also for PMMRI (post mortem magnetic resonance imaging), SVAPMMRI [39] (following terminology agreements [33]).

8

10 10 8 7 6 5

8

water

4 3 2

6

flowrate L/min

flowrate L/min

water

4

PEG

1 0.8 0.7 0.6 0.5 0.4 0.3

2

PEG

0.2

0

0.1 5

10

15

20

25

5

volt

10

15

20

25

volt

Figure 5: Voltage-dependent flow-rates for both water (diagram: +) and more viscous PEG (diagram: ×) using the very low cost immersion pump (model 0444, Barwig, method section) (linear regression; water R2 = 0.96, PEG R2 = 0.99). Linear regression (same data in both diagrams – left diagram: linear flowrate scale; right diagram: logarithmic flowrate scale) shows a linear relation between pump voltage and both watery (higher) and viscous (lower) fluid’s flow rates. For PMCTA targeted flow rates between 0.2 and 0.8L/min, PEG is best pumped with pump voltages between 5 and 10 volts, which is easily identified on the logarithmic voltage-flow rate plot (right diagram). This coincides with this particular pump model’s permament usage’s comfort zone of 5-9V to avoid overheating under prolonged usage.

4.1. Cost IP PMCTA is calculated for hardware costs of less than a percent of a commercial top-of-the-line solution. Also, standard injectors have been demonstrated to achieve successful vascular filling [40]. There are even more economical methods. Administering CPR type chest massage [30] to a deceased in order to circulate contrast agent is free of hardware cost. However, it may confound findings or technically fail in decomposed or trauma cases. Another technique would require manually administering contrast agent into the body by use of regular injection or infusion techniques [41].

4.2. Handling Handling of the small immersion pump has both advantages and challenges. It is very small and light so it is mobile and does not require a lot of storage. Handling characteristics could be improved by an affordable wire frame that fixes the pump to the container.

4.3. Pump performance While so far, no specific advantage of a roller or peristaltic pump over a centrifugal pump for PMCTA has been made public, our first results show that they perform equally well. The very low cost pump exhibits the typical characteristics of a centrifugal pump. Its flow rate both depends on voltage and the fluid’s viscosity (Fig.

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Figure 6: Cleaning the very low cost immersion pump is achieved by immersing it in detergent containing water and pumping that fluid, thus both cleaning the pump from its outside and inside while transporting the water from the fluid container (orange portal) to the sink (blue portal).

5). A quantitative flow rate and voltage correlation can be achieved within a short amount of time using simple means. To deliver carefully dosed PMCTA that automatically reduces pressure, roller pump systems would require a costly control system logic connected to intravascular pressure monitoring. This small centrifugal pump will reduce output against significantly increased pressure by itself.[42]

4.4. Imaging The vessel filling both regarding overall aspects (Fig. 3, 4) and details (Fig. 2) are similar between both IP PMCTA and HLM PMCTA.

4.5. Outlook For the most part, the end user of forensic PMCTA will be a typical government institute that covers forensic medicine. Free accessibility, the option for critical appraisal as well as affordability are paramount characteristics of the materials used. Whole industries were able to unfold their potential only after affordable and economic products were built and sold, such as the automobile industry [43]. The International Society of Forensic Radiology and

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Imaging (ISFRI)2 is a platform that engages in and encourages open dialog. With that, one question is just how many technical features are really needed and what the cheapest options really are. Advanced post mortem angiography techniques employ both arterial and venous filling phases with an added back-and-forth type third phase [12, 44]. Manually switching between two simultaneously attached immersion pumps - one for arterial, the other for venous access - could be a relatively simple option without significantly increasing hardware expenses. Furthermore, adding intravascular pressure sensors to the setup may also help to exceed visualization quality to beyond what current setups may provide without excessive extra cost. The best choice for very affordable PMCTA contrast agent solution is not clear either. In some jurisdictions drainage of oily substances into the common sewerage and burial of oil contaminated bodies in gravesite burials may be regarded as an environmental hazard [45, 46, 47, 48, 49].

5. Conclusions Very affordable post mortem CT angiography may not only be financially easy to accomplish, but not difficult to perform technically. In order to become a widely accepted tool, PMCTA must be performed with materials that are as affordable as possible, and this is a clear step into that direction. This IP PMCTA technique is simple in handling, at low cost and therefore disposable for institutes that work within tight economical budgeting and offers a potential PMCTA solution for any forensic facility world-wide.

Competing interests The authors declare that they have no competing interests. In particular, they have no pending or published patents regarding contrast agents, pumping devices or other materials relevant to conduct post mortem computed tomography angiography.

Acknowledgements The authors thank members of the Virtopsy team for their valuable discussion and manuscript editing.

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