Results of a Technically

Difficult Patient Study

Six sites in North America and Europe

The C5-1 PureWave transducer with Philips tissue aberration correction and coded
The prevalence of obesity
beamforming technologies was tested at 2 sites in Europe and 4 sites in North America.
is a global problem rising Each site was asked to complete 50 to 75 technically difficult patient ultrasound exams using
at alarming rates. Statistics the C5-1 transducer and compare results based on previous experience with conventional
technologies. The results of the study are on the follow pages.
show that 25 to 50 percent
of abdominal exams are Clinical sites in the Technically Difficult Patient Study
large patients that present The study’s participating clinical sites were:
• University of Alabama Hospital and the Kirklin Clinic; Birmingham, Alabama
challenges of longer exam
• University of Texas M.D. Anderson Cancer Center; Houston, Texas
times, sonographer injuries • Cliniques Universitaires Saint Luc UCL; Brussels, Belgium
and less definitive diagnoses. • University of Colorado; Denver, Colorado
• St. Paul’s Hospital; Vancouver, BC, Canada
• Freeman Hospital; Newcastle Upon Tyne, UK

Summary of results
Below are the combined summary results from the participating sites. Individual
results from each site can be found in the following pages.
• Exam times reduced from 2% to 38%.
• A reduction in pain and fatigue from scanning in 29% to 85% of the cases.
• Sonogaphers felt that they had to push less in 48% to 93% of the cases in order
to achieve penetration of an organ or structure.
• Marked improvement in color sensitivity in 31% to 86% of the cases.
• Using the C5-1 transducer prevented a recommendation for additional studies with
CT and/or MR due to an inadequate ultrasound study in 8% to 69% of the cases.
Philips innovations
C5-1 transducer design
Extraordinary design efforts have resulted in a new transducer
that is both lightweight and easy to hold for reduced fatigue during
scanning. The C5-1 features a highly flexible cable and optimal
transducer balance that contributes to scanning comfort during
extended or difficult exams. In addition, minimized elevation
dimension improves intercostal access when imaging challenging
patients with reduced rib spaces.

PureWave crystal technology

The C5-1 is the first application of Philips exclusive PureWave
crystal technology to a curved array transducer. PureWave
crystals are the result of new manufacturing techniques that
create a near-perfect atomic level arrangement. The uniformity
and lack of grain boundaries help transfer energy with up
to 85% greater precision and efficiency over conventional
materials. Their extended bandwidth covers the frequency
Conventional PZT material (800x) PureWave crystal material (800x) range of two transducers, with improved Doppler performance
and highly sensitive harmonic imaging.

Tissue aberration correction technology

A main cause of ultrasound image degradation arises from
the improper assumption of speed of sound characteristics
when scanning patients with significant adipose layers.
The resulting beam aberrations account for the loss of
detail resolution seen on obese patients. For the first time,
the C5-1 transducer works in conjunction with the iU22 to
accommodate for the altered speed of high frequency sound
waves through adipose layers versus other tissue. In this unique
mode, the ultrasound system becomes “aware” of increased adipose
content and applies aberration correction algorithms. The result is increased
sharpness and clarity in image quality throughout the entire beam length.


University of Alabama Hospital
and the Kirklin Clinic
Birmingham, Alabama Describe the Technically Difficult Patients that you encounter in your lab.
Michelle L. Robbin, MD We have a large proportion of obese patients whose livers and other abdominal organs are
Franklin Tessler, MD more than 4-5 centimeters deep, representing a significant diagnostic challenge. Additionally,
we have large numbers of people with hepatic steatosis, diagnosed as an echogenic liver of
varying severity. A significant proportion of our patient's livers are so fatty that we can only say
they have a liver, but cannot characterize it further.

What happens when you encounter a technically difficult patient?

It definitely takes longer to perform an ultrasound on a difficult patient. Image optimization
is more difficult, and the sonographer has to work harder to create acceptable images. The
sonographer may have to try several different probes before settling on the probe that provides
adequate penetration yet yields diagnostic images. We perform a large number of challenging
abdominal Doppler studies on cirrhotic patients, patients with suspected renal artery stenosis,
and immediately postoperative liver transplant patients. Acquiring images and Doppler
waveforms quickly has been a challenge before the iU22, especially in the small cirrhotic liver.
The patient has to be sent to CT or MR when we are unable to confidently exclude liver
lesions, which is often impossible in a cirrhotic patient, or one with severe steatosis.

Summarize the results of your technically difficult patient study using the C5-1.
At least one of my sonographers typically has finger and hand numbness during a long renal
artery Doppler study. When she used the C5-1 probe, she did not have finger and hand
numbness because of the superior transducer ergonomics. In another study, we were able to
get diagnostic images of the renal artery stenosis we suspected was present but were unable to
demonstrate without the abdominal penetration mode.

• Exam time reduced 19%

• A reduction in pain and fatigue from scanning in 77% of the cases
• Sonographers felt that they had to push less in 77% of the cases in order to achieve
penetration of an organ or structure
• Marked improvement in color sensitivity in 79% of the cases
• The C5-1 prevented a recommendation for CT or MR, due to inadequate ultrasound
study, in 43% of cases

“We sonologists loved the images— ‘What a great image’ was

a frequent comment.”

“Good penetration of fatty liver”

“We clearly showed innumerable liver lesions in a patient in whom an

ultrasound previously from another vendor only showed a heterogenous liver.
Similarly, we showed many more liver lesions in another patient with the iU22”


University of Texas M.D. Anderson Cancer Center
Houston, Texas Describe the Technically Difficult Patients that you encounter in your lab.
Dr. Deepak Bedi Large patients, fatty liver, liver/renal/abdominal pathology, large fibroids, gassy patients,
ICU patients.

What happens when you encounter a technically difficult patient?

It takes more time to do the ultrasound exam. There is greater strain on the sonographer.
It takes more of the radiologist’s time.

Summarize the results of your technically difficult patient study using the C5-1.
Found it easier to see deep organs on large patients. Did not have to “reach” and strain to
find an acoustic window.

• Exam time reduced by 16%

• A reduction in pain and fatigue from scanning in 30% of the cases
• Sonographers felt that they had to push less in 48% of the cases in order to achieve
penetration of an organ or structure
• Marked improvement in color sensitivity in 61% of the cases
• The C5-1 prevented a recommendation for CT or MR, due to inadequate ultrasound
study, in 9% of cases

“Useful for critically ill patients, with multiple lines, tubes etc,
where the C5-1 allows you penetration without looking for
the ideal acoustic window.”

“Particularly suitable for imaging deep-seated kidneys and liver,

without sweating over the anterior approach.”

“Sonographers did not have to re-arrange equipment,

reposition themselves or dig hard to get images.”


Cliniques Universitaires Saint Luc UCL
Brussels, Belgium Describe the Technically Difficult Patients that you encounter in your lab.
Etienne Danse, MD, PhD Obesity and fatty liver, modification of the liver texture related to chemotherapy, large
Mohamed Kichouh, Sonographer amounts of bowel gas, non-cooperative patients, post-operative evaluation (in critical
care units) with a large amount of color Doppler studies of the liver and the kidneys, large
amount of color Doppler studies of the kidneys in patients with hypertension, diabetes
mellitus and renal function impairment.

What happens when you encounter a technically difficult patient?

Increased time for the examination (sometimes with a doubling time), increased pressure on
the skin, in some of these cases the ultrasound results are not enough for giving an optimal
answer and the patients are referred to MR or CT.

Summarize the results of your technically difficult patient study using the C5-1.
• Exam time reduced by 38%
• A reduction in pain and fatigue from scanning in 85% of the cases
• Sonographers felt that they has to push less in 86% of the cases in order to achieve
penetration of an organ or structure
• Marked improvement in color sensitivity in 86% of the cases
• The C5-1 prevented a recommendation for CT or MR due to inadequate ultrasound
study in 69% of the cases

“The increased performance of color mode reduces the

time to insonate the majority of the patients, particularly
in cases of color Doppler of the kidneys.”

“The C5-1 is more ergonomic and pleasant to use

resulting in a reduction of fatigue at the end of the day.”

“The sites of treated lesions were clearly better

delineated with the C5-1.”


University of Colorado Hospital
Denver, Colorado Describe the Technically Difficult Patients that you encounter in your lab.
Julia A. Drose, BA, Obesity, large amount of subcutaneous fat (not necessarily an obese person), cirrhotic
RDMS, RDCS, RVT livers, fatty livers, massive ascites, abdominal scars, thin-kyphotic patients, twin pregnancy,
pregnant with polyhydramnios.

What happens when you encounter a technically difficult patient?

Technically difficult patients often take longer to examine and their exams are usually
less diagnostic. An additional test, such as a CT, is often recommended secondary to the
diagnostic limitations of the ultrasound exam. Sonographers do have to push harder or scan
in awkward positions in some cases. This causes pain at the time of the exam and probably
contributes to long term injury or disability. The most important consequence of imaging
a technically difficult patient is that we often cannot provide a diagnostic answer to the
clinical question.

Summarize the results of your technically difficult patient study using the C5-1.
The C5-1 PureWave transducer was considered an asset to all of our sonographers. It did
improve imaging in difficult patients. In 47 out of 63 cases (75%) the sonographer felt the
C5-1 improved their diagnostic confidence in the exam.

• Exam time reduced 2% to 3%

• A reduction in pain and fatigue from scanning in 29% of the cases
• Sonographers felt that they had to push less in 52% of the cases in order to achieve
penetration of an organ or structure
• Marked improvement in color sensitivity in 78% of the cases
• The C5-1 prevented a recommendation for CT or MR, due to inadequate ultrasound
study, in 8% of cases

“Great improved penetration—visualization of structures”

“Improved penetration of fatty liver”

“Didn’t press hard, patient in pain—still got good image”


St. Paul’s Hospital
Vancouver, British Columbia Describe the Technically Difficult Patients that you encounter in your lab.
Cathy Fix, RDMS, Obese patients, fatty and cirrhotic livers, technically challenging patients with poor
Ultrasound Supervisor acoustic windows.

What happens when you encounter a technically difficult patient?

This has a significant impact to our lab in having to spend more time on each patient, making
fewer exams possible, and decreasing diagnostic confidence. This increase in difficulty also
places more physical strain on our sonographers, which can lead to injury as well as creating
the need for further diagnostic imaging tests when the ultrasound examination does not give
optimal results.

Summarize the results of your technically difficult patient study using the C5-1.
We increased our diagnostic confidence for all of our obstetrical exams. We also increased
confidence in liver exams including technically difficult patients and those with fatty
infiltration or cirrhosis.

• Exam time reduced 4%

• A reduction in pain and fatigue from scanning in 54% of the cases
• Sonographers felt that they had to push less in 64% of the cases in order to achieve
penetration of an organ or structure
• Marked improvement in color sensitivity in 31% of the cases
• The C5-1 prevented a recommendation for CT or MR, due to a suboptimal ultrasound
examination, in 29% of cases

“Didn’t have to work so hard to get diagnostic images”

“Increase in diagnostic confidence especially with fetal heads and fetal hearts”

“We need penetration and good spatial and

contrast resolution and the C5-1 has those”

“Lack of artifacts helping increase our diagnostic confidence”


Freeman Hospital
Newcastle Upon Tyne, UK Describe the Technically Difficult Patients that you encounter in your lab.
Dr. Simon T. Elliott and Team Mostly obese patients and fatty livers; a lot of requests for retroperitoneal pathology
and Doppler studies.

What happens when you encounter a technically difficult patient?

In difficult patients, the main problem is reduced diagnostic confidence, due to limited
access or sensitivity.

Summarize the results of your technically difficult patient study using the C5-1.
The C5-1 definitely improves diagnostic confidence through better penetration and
colour Doppler sensitivity. It also increases the speed of the exam and helps in
uncooperative patients.

• Exam time reduced by 34%

• A reduction in pain and fatigue from scanning in 87% of the cases
• Sonographers felt that they had to push less in 93% of the cases in order to achieve
penetration of an organ structure
• Marked improvement in color Doppler in 71% of the cases
• Without the C5-1, 19% of the cases would have been referred to MR or CT

“Good penetration of fatty liver”

“Excellent in difficult scarred abdomen”

“Increases speed and confidence for gallbladder and bile ducts”

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