This article originally appeared in the April 2012 print edition of DOTmed Business News

“Sedate” was the word used to describe the mobile C-arm equipment market’s growth patterns in a report published by research firm Global Industry Analysts, Inc. this past November. Emerging alternatives in radiography and
the mature market are the main components preventing growth, with most of the demand coming from replacement sales to existing clients. Major players include GE Healthcare, Philips Healthcare, Siemens Medical Solutions and Ziehm Imaging GmbH.

Excluding mini C-arms, the global market for fluoroscopy and mobile Carms was estimated at 9,403 units in 2011 and projected to grow to 11,486 units and $1.4 billion by 2017, says GIA’s report.

In developed markets like the U.S. and Western Europe, business has been fairly steady, with the U.S. representing the largest market worldwide. Meanwhile, in the emerging markets of China, Brazil, Russia and the Middle East, business has been strongly up over the past year and is becoming more aligned with developed markets, according to Joe Shrawder, president and CEO of GE Healthcare Surgery.

“Some emerging countries are adopting newer technology later because their economic growth cycle and maturity is coming later,” he says. “Minimally invasive surgery is becoming much more common in emerging countries.”

Minimally invasive procedures and 3-D
Minimally invasive procedures and the evolution of new application areas will drive the growth of mobile C-arms, according to GIA’s report.

“A shift from traditional open surgery to minimally invasive surgery often requires the use of visualization or imaging where the surgeon cannot see with direct line of sight,” says Shrawder. “The developing world’s [surgical teams are] becoming better at it and more aware of it and more conscious about providing patients with the best available surgical techniques.”

The evolution of new application areas, including the ability to image the body’s torso and head — as opposed to only extremities — is another segment that will help the C-arm industry to boom. Ultimately, demographic trends toward a heavier, aging population will drive procedure growth, according to Mark Manum, director of marketing for Philips Healthcare’s OR channel.

“The population in general is getting older and the U.S. is getting heavier; those two factors coincide with some health issues that mobile C-arms are used for, including image guidance during spine surgery, orthopedic trauma surgery, joint replacements and vascular surgery,” says Manum.

Advanced imaging capabilities have been a hot topic in the C-arm market during the past 12 months. A popular option for spine surgery procedures is 3-D image reconstruction.

“3-D image reconstruction on a C-arm is competing with a more dedicated CT-like imaging procedure to get a good axial view of the spine,” says Shrawder. “Going with the trend towards more minimally invasive spine surgery, 3-D views will enable that field to make the progress they are looking for.”

Another big trend in the industry has been the merging of more C-arm technologies. For example, Ziehm has started to combine 2-D imaging with a 3-D module on one platform.

“Further trends are the open interface to medical equipment in the periphery, such as navigation systems,” adds Martin Herzmann, Ziehm’s director of global marketing. “The communication between the numerous systems that interact in the OR will certainly play a bigger role in the future.”

The Great Divide: FD and II
Last year, flat panel detector technology was just beginning to gain market attention. And according to Jeff Weiss, CEO of refurb company Atlantis Worldwide LLC., the new technology is still just a blip on the radar.

“I would have thought people would have wanted FD as opposed to image intensifiers, but that new technology does not seem to be a reason for facilities to buy the new system,” he says. “Plus, you are looking at a price difference of $200,000 versus $100,000 or less in general.”

The more sophisticated and knowledgeable customers will most likely focus not on technology for the sake of technology, but on best image quality and best dose combination. According to Shrawder, these customers aren’t ready to move to flat panel detector technology yet.

“FD tends to add cost, reduce reliability of the system, and worst of all, requires more X-ray dose to provide the same image quality as the II or analog version of a C-arm,” he says. “It seems FD has been launched by some companies prematurely, before it was actually creating tangible benefits for the users.”

This appears to be reinforced by the pre-owned market, as 99.99 percent of C-arms still have IIs, according to Matthew Blaustein, president of refurb company Bluestone Diagnostics Inc.

However, not everyone agrees with the opinion that FD has yet to make a move on the market, as other companies view its continued adoption as the sector’s biggest news over the past year. FD has gone from being a technology Philips was only really discussing with major teaching hospitals, to being a technology the company now discusses with nearly every customer. Manum notes that he isn’t just seeing this with Philips’ full-sized C-arms, but also in the mini C-arm realm.

“I think [flat panel detector] is a technology that customers are becoming more comfortable with, they have a better understanding of, and an appreciation for the benefits of the image quality advantages of flat detectors,” says Manum. “Customers are starting to recognize the advantages of the higher dynamic range of flat detectors versus image intensifiers and superior resolution.”

Philips’ units have been selling well; particularly, the Veradius system and Veradius neo product lines have piqued customers’ interest.

“We have gone from selling mostly image intensifiers to almost parity between image intensifiers and flat detector systems,” says Manum.

But as more and more companies jump onto the flat panel detector bandwagon, competition is increasing. At least five companies were showcasing new flat panel detector systems at RSNA’s show and conference in November, according to Manum. He notes that this is an indication that the market is really starting to shift.

To get a historical market perspective, it helps to compare flat panel detector
technology in fluoroscopy and angiography, according to Herbert Westin, the senior director of product marketing for surgery and urology at Siemens Healthcare. When it was first introduced several years ago, health care providers saw the advantages in angiography and switched fairly quickly. Fluoroscopy rooms are now moving toward the technology.


“On the urology side, we have an II-based system called the UROSKOP Access, and an FD-based system the UROSKOP Omnia,” says Westin. “The market is switching and accepting the FD technology faster even if it is more expensive.”

For Ziehm Imaging – the first company to introduce flat panel technology to the C-arm sector the – technology is a major revenue and market driver. More than one-third of all systems sold by the company are now flat panel detector units.

Richard Keil, Hologic, Inc.’s Fluoroscan sales and marketing director, has high hopes that new flat panel detector systems will grow the market for mini C-arms, with the biggest impact occurring in the next 12 to 24 months.

“Business had been relatively flat for the mini C-arm market over the past few years,” says Keil. “However, we see significant interest in our work-in-progress Fluoroscan InSight-FD mini C-arm.”

Although GE has seen very little erosion of business toward flat panels from its customers, Shrawder believes the technology will be the direction of the future.

“I won’t sit here and tell you FD isn’t going to happen,” says Shrawder. “Future generations of FDs will have increased sophistication and reduced cost of electronics versus image intensifiers and at that point, the whole industry will shift. Until then, it’s just out there as more of a glimpse into the future that’s not really fully baked yet.”

Manum predicts a continued evolution as customers further embrace digital technology over analog technology, but warns that the service of equipment may be affected with flat panel detector technology’s increased adoption.

“The performance of FD doesn’t diminish with time like image intensifiers,” says Manum. “There is a point in time when you have to replace an image intensifier because the [imaging quality] has degraded and that shouldn’t be taking place with a flat detector. So as more and more digital systems replace analog systems, the servicing will change in that way.”

Fixed vs. mobile
As demand for fixed C-arms in the operating room rises, one of the challenges customers face is to what extent hybrid ORs play into the hospital’s strategy for managing surgery.

“Toshiba does not market portable C-arms in the U.S. because the place where these portable C-arms are primarily used [the OR space] is trending towards going with permanently installed high-end products rather than portable C-arms,” says Dick Werner, product manager in the XRVL business unit for Toshiba America Medical Systems.


Toshiba’s ceiling-mounted and floor-mounted C-arms have an
advantage in mechanical flexibility over the competitive systems on the market, according to Werner. Both offer standard lateral movement, the ability to easily move from the left to the right side of the operating table, as well as pivot around the patient. In fact, Toshiba’s Five Axis Floor Mount, on the market since 2007, won industry awards from KLAS for its flexible mechanical motions. Other OEMs, including Philips, have followed Toshiba’s example.

“We’ve had a lot of customers request new geometries for C-arms, so we’ve adapted that by redesigning our Veradius mobile C-arm and introducing the Veradius neo system that has an optimized geometry for easier positioning, even when we get a very big patient on the table,” says Philips’ Manum. Veradius neo is Philips’ newest system and will ship later this year.


“Philips has given us a compliment by adding an expensive ceiling structure option that will move their ceiling-mounted C-arm laterally,” says Werner. “They see the benefit in the feature that we introduced with this generation of C-arm back in 2001.”

But ceiling-mounted and floor-mounted C-arms come with disadvantages too.

“When you hang a C-arm from the ceiling in the OR space, the carriage the C-arm rides on can become an impediment to the laminar airflow necessary for an open surgical procedure,” Werner says. “On the counter side, the floor-mounted C-arm becomes an obstacle when the room is not being used for imaging, but rather for a conventional procedure.”



Challenges: Radiation dose
“When we ask customers what their biggest issues or worries are about C-arms, dose rarely comes up,” says Shrawder. “But when we specifically ask about dose, they say, ‘Oh yes, of course we are concerned.’ It seldom comes from them spontaneously.”

Regardless, Shrawder notes that dose is definitely on customers’ radars, more so than in previous years. He attributes this to a higher level of awareness and ongoing press coverage. Accordingly, most manufacturers are making incremental modifications to existing technology, with a focus on reducing radiation dose.

In November, GE announced an additional $300 million investment in low-dose technologies and unveiled an array of radiation-dose management offerings. Representing more than $800 million of investment over 15 years, GE’s technologies include dose-reporting solutions, unique image reconstruction techniques, far-reaching Dose Check upgrades, free iPad apps and online courses promoting dose-conscious care.

Siemens also has an approach to lowering dose, called CARE (Combined Applications to Reduce Exposure),which has been going for over 10 years.

“Besides building our systems to minimize dose, we focus on training our users to help ensure that they are using the least amount of dose possible while obtaining the highest quality images,” says Siemens’ Westin.

One way of reducing dose levels is to provide images via pulsed wave, using a system like Philips’ Veradius mobile C-arm with flat panel detector technology.

“We have found pulsed wave produces less radiation than nonpulsed wave,” says Greg Sebastian, a radiologic technologist at the Lubbock Vascular Access Center in Texas.

Cost vs. value
In the last year, there have not been any big product announcements, with many companies fine-tuning the systems they have without making any major platform changes. This lack of significant technical breakthrough may be due to the slowing growth in developed markets like the U.S. and Europe. However, the C-arm service sector is still growing. This is especially true for the U.S. market, where there exists much uncertainty about the ramifications of health care reform. Likewise, the European market has its own concerns about the overall health of the European economy. As a result, customers are keeping their older C-arms longer and longer.



“With C-arms, why would someone commit to a new machine when a used one costs less and the billing is the same?” asks Leon Gugel, president of refurb company Metropolis International LLC. “The problem is when the OEMs don’t sell a lot, there are less trades; this in turn affects the pre-owned market,” he adds.

Because lower-cost value products have been more prevalent in the last 12 months, the average price for a C-arm is lower this year than last.

“Prices are 5 percent lower than a year ago,” says Shrawder. “If you took a company’s total revenue and divided it by the total units sold, the revenue per unit is down 5 percent year-over-year.”

With mobile C-arms in completely new clinical areas such as
minimally invasive heart valve implantation, the costs for the units have been established in a price range far below fixed installed C-arms, but slightly above C-arms traditionally used in conservative and established applications such as pain management or trauma. Regarding permanently installed C-arms, Werner explains equipment costs have been steady for the past few years, though some related costs are going up — typically from third-party suppliers.

On the pre-owned or refurbished C-arm side, equipment costs have been steady over the past several years, according to Bluestone’s Blaustein.

“My records show that a refurbished GE OEC 9800 basic system for pain management in 2008 sold for essentially the same price that such systems are selling today (approximately $85,000 with full warranty),” he says. “Also, pre-owned or refurbished systems from other manufacturers have generally held their value pretty well over the past few years.”

Possibly this is because technological advancements from the manufacturers have not been extensive enough to have a negative effect on the market for used or refurbished C-arms. In addition, facilities with reduced budgets and reimbursements are either adding used systems to save money or are keeping what they have.

Regardless of a decline in reimbursements, GIA says the C-arm market continues to remain cost-effective when compared to MRI and CT systems.

“For CT and MRI, procedures are reimbursed at a specific rate,” says GE’s Shrawder. “For C-arms, it’s the surgery itself that’s reimbursed, not necessarily the use of the C-arm. As there is pressure in surgery to reduce costs, C-arms can assist in the reduction of cost by shortening the surgery time; it has net-positive economic value when factored in.”

Lubbock Vascular Access Center’s Sebastian agrees that a new, good quality C-arm pays for itself. “If you’re not having to waste time messing around with the C-arm, if you can produce more procedures in the eight-hour time period, and if you can get better image quality — this reduces your time in the procedure room,” he explains. “I see that as an increase in reimbursement.”