The desire to improve image quality is pushing ultrasound manufacturers beyond the capabilities of traditional 2-D imaging and increasing the roll-out of 3-D and even 4-D ultrasound equipment.

Over the years, the ultrasound market has witnessed many technology innovations. Manufacturers have focused on design to make equipment portable and more mobile. Some of the technological inventions include ultrasound equipment with wireless transducers, contrast-enhanced imaging, volume imaging, and elastography. These advancements have allowed physicians to capture images of blood flow and blood perfusion, enabling them to take real-time 3-D images of the internal structures of the human body, allowing them to properly distinguish between malignant and benign tumors. These have helped physicians to overcome problems faced while using traditional ultrasound equipment. The global ultrasound market has grown at a rate of 4.76 percent in 2015, accounting for revenue of USD 6.38 billion. The market is expected to reach USD 8.16 billion over the next 4 years owing to an increase in demand for advanced ultrasound equipment.

The Indian ultrasound equipment market in 2015 has also increased by 8-10 percent over 2014 in all four segments including premium, high-end, mid-end, and entry level. The steady influx of low-cost ultrasound machines due to reduced import duties, increased local production due to surge in demand, and easily available technology has heightened competition pushing down the procurement cost in India, thus forcing major players to reduce their margins and increase focus on technological innovations with greater precision and accuracy along with greater emphasis on patient care. These innovations will continue to expand as physicians compare ultrasound with other imaging modalities when choosing how to best diagnose and plan interventional procedures.

Technology Trends

Ultrasound imaging took some major steps forward in 2015, with innovative new equipment and technologies debuting across multiple market segments. From new premium-tier systems to the expansion of handheld, point-of-care (POC) solutions, vendors focused on improvements in image quality, productivity, and ergonomics. Current equipment, however, is able to produce high-resolution diagnostic images in three dimensions, including real-time surface-rendered images, whereas CT and MRI still have limited real-time imaging capabilities. This has made the technology readily available in multiple medical settings, and with its reduced cost the equipment is becoming increasingly popular in developing countries.

3-D and 4-D ultrasound optimizing visualization. The desire to improve image quality is pushing ultrasound manufacturers beyond the capabilities of traditional 2-D imaging and increasing the roll-out of 3-D and even 4-D ultrasound equipment. At first, 3-D was cumbersome to use because someone had to sort through all the data and manually delineate the anatomy of interest to measure. However, recent system now automates this process, reducing the time it takes closer to that of 2-D exams. Automation also makes quantification more consistent and reproducible, which is bringing 3-D into mainstream clinical practice. This utilizes advanced algorithms to capture much larger amounts of data - roughly a DVD worth of data per second - and selects pixel-by-pixel the most precise information to display. 4-D ultrasound has also begun making its way into the market, adding motion into a scan.

Electronic matrix array transducers gaining traction. Subsequent development has led to ultrasound equipment that use conventional transducers for manual acquisition of volumetric data with or without position-sensing devices. This has resulted in less optimal image quality compared to the automated or volumetric transducers, which are being phased out. More recently, fully electronic matrix array transducers capable of producing 3-D images without the use of any moving parts have been introduced. Volumetric scanning capabilities initially developed for the convex transducer have been gradually introduced to linear and endocavity transducers, expanding the use of 3-D ultrasound in other areas including abdomen, breast, and female pelvic area, which can acquire volumetric data within only a few seconds for each plane. Further improvements in transducer technology have enabled real-time 3-D displays.

Reshaping clinical ultrasound by CEUS. The recent decade has witnessed great improvement of contrast-enhanced ultrasound (CEUS) and its extensive use in clinical practice, which is undoubtedly the major breakthrough in the field of diagnostic ultrasound in recent years. The current popularization of CEUS is largely due to the emergence of low acoustic power contrast-specific imaging mode and micro bubble-based contrast agent filled with inert gas. Some new techniques are also tentatively used together with CEUS. 3-D-CEUS is a useful supplement to 2-D-CEUS, which may offer direct, accurate, and comprehensive diagnosis of early endometrial carcinoma. However, the real impact of this new technique on clinical practice needs more confirmation in future studies.

Software development for faster reinterpretation of data. Improvements in data acquisition and processing allow for almost isometric reconstruction of the data to useful images in planes other than the one originally acquired. A number of proprietary software programs have been developed for manipulation of volumetric data. Depending on the manufacturer, the volumetric data may be reprocessed into slices similar to those used in CT and MRI. Such capabilities allow for a more efficient workflow, as volumetric data can be obtained through standard acquisition methods, and image analysis may be performed off-line. Software developments combined with faster processors have allowed faster reconstructions and reinterpretation of data. Software developers are also helping to improve 3-D ultrasound visualization.

Challenges and Opportunities

Innovations including advent of 3-D and 4-D imaging, increase in the number of cancer patients, rise in the prevalence of CVD and other lifestyle-oriented diseases, and a constant rise in birth rates and awareness amongst the masses are creating opportunities for the market players.

Although the visualization improvements with 3-D ultrasound are undeniable; the technology has yet to see widespread adoption. While the technology has advanced, providers have been slow to adopt it, partly due to the lifespan of their current systems, the cost of 3-D and 4-D systems, and the need for more data to establish a benefit for the increased costs for the newer technology. The market is restrained by reimbursement policies in emerging nations. The high price and unavailability of reimbursements keeps a large number of patients from using ultrasound services.

Future Outlook

The future holds for the agile companies with lower overheads and significant advantages in R&D costs who are perfectly positioned to seize the massive opportunity to create a mark for themselves in a market that once shied away from thinking beyond a few MNCs.

On technology front, image fusion combined with other imaging modalities might play an increasing role in the future, allowing complementary modalities to offer a complete picture in one view. The next level of fusion imaging would be CT angiography (CTA) combined with 3-D ultrasound, which shows the detailed anatomy of the heart and coronaries.

Spatial compounding enabled by 3-D ultrasound is another area that will play an increasingly important role, especially during interventional echo-guided procedures. Since it collects data for a volume of anatomy, not just a slice of imaging data, it can be rendered electronically to show multiple views of the same anatomy without the need to move the transducer, which essentially enables a panoramic anatomic view. Sub-harmonic imaging has also been anticipated as a novel method for isolating ultrasound micro bubble signals while suppressing the surrounding tissue signals. It is expected that this new technique may improve the signal-to-noise ratio compared with the current CEUS technique, which will finally provide more detailed information about microcirculation in the regions of interest, and it has more potential in the future.

Dr BYT Arya, Consultant Radiologist, Manipal Hospital,Bangalore
Second Opinion
Viewing through Sound

Ultrasound equipment which came into medical practice in 1970s has grown exponentially. Today, ultrasound is extensively used in both diagnostic and interventional procedures in all branches of medicine through radiology.

Advantage of ultrasonography over other imaging modalities includes no usage of ionising radiation; no health hazard and safety in pregnancy; easy availability; cost-effectiveness; portability; non-invasive diagnosis of range of conditions in different parts of the body, including the abdomen, pelvis, blood vessels, breast, kidneys, muscles, bones, and joints; real-time examination which is helpful in echocardiography, foetal examination; and interventional procedures for guidance; and Doppler examination for blood-flow assessment, which helps in diagnosis of obstruction and stenosis.

Disadvantages of ultrasonography include operator-dependence, requirement of skilled radiologists or clinicians for proper interpretation; otherwise ultrasound can become a hazardous tool, and its inability to penetrate bones and air, has limited role in examination of the lung and bones.

In India, PC PNDT Act is mandatory for installation of ultrasound unit and for ultrasound examination.

Doppler application has significantly contributed in evaluation of the vascular structures. Advancements in ultrasound technology like 3-D and 4-D volume probes, cordless probes, cross-beam technique, elastography, fusion imaging, and ultrasound contrast have improved the diagnostic accuracy. Ultrasound has no risk, is cost-effective, and is a widely used imaging modality which helps in diagnosis and interventions of a range of medical conditions.

Dr BYT Arya
Consultant Radiologist,
Manipal Hospital,Bangalore

Dr Vivek Sharma, Senior Consultant, Medanta the Medicity, Gurgaon
Second Opinion
The New Trend

Ultrasound equipment is mostly manufactured in USA, Europe, Japan, and Korea. Depending on the work profile, radiologists procure equipment which give good commercial and clinical outcome. For optimal usage in diagnostic centers, equipment ranging from Rs.15 lakh to Rs.25 lakh would be more suitable. Cost of equipment and resale value also depends on the number of probes. At least three probes are necessary, namely, convex, linear, and TVS. If the machine has cardiac software, cardiac probe can be added. In corporate hospitals, equipment with the latest technology and features like ARFI (elastography), contrast-enhanced ultrasound imaging, and high-resolution-compatible probes for MSK scans and 3-D, 4-D technology could be cost-effective.

Some companies supply refurbished equipment, or have buy-back, or exchange policy which can be a lucrative offer for some. Tertiary care centers where specialized treatments are given have equipment that are to be certified by manufactures or FDA/ISO, and this would raise the cost. In general, requirements should focus on good resolution, warranty, return policy, after-sales service, and for how long the equipment would be used with ever-advancing technology.

As of now, market trends have been favoring established manufacturers in USA, Europe, and Japan. Asian market is still growing and will have to establish itself to be a significant competitor. Factors such as healthcare development, infrastructure improvement, and government initiatives will boost rapid growth. Aging population, health checks, and public-private funds can encourage this trend further.

Ultrasound incorporated in minimally invasive surgery equipment and diseases like cancer would propel use of ultrasound technology in therapeutic procedures like HIFU, and demand for non-surgical procedures would favor technology like ESWL.

From buyer's perspective, cost-effectiveness and value-for-money is important, and as the market is growing fast, new opportunities for ultrasound industry have tremendous scope in future.

Dr Vivek Sharma
Senior Consultant,
Medanta the Medicity, Gurgaon

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