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Background: Out-of-plane lesions pose challenges for CT-guided interventions.Augmented reality (AR) headset devices have evolved and are readily capable toprovide virtual 3D guidance to improve CT-guided targeting.  Purpose: To describe the design of a three-dimensional (3D) AR-assistednavigation system using HoloLens 2 and evaluate its performance throughCT-guided simulations.  Materials and Methods: A prospective trial was performed assessing CT-guidedneedle targeting on an abdominal phantom with and without AR guidance. A totalof 8 operators with varying clinical experience were enrolled and performed atotal of 86 needle passes. Procedure efficiency, radiation dose, andcomplication rates were compared with and without AR guidance. Vector analysisof the first needle pass was also performed.  Results: Average total number of needle passes to reach the target reducedfrom 7.4 passes without AR to 3.4 passes with AR (54.2% decrease, p=0.011).Average dose-length product (DLP) decreased from 538 mGy-cm without AR to 318mGy-cm with AR (41.0% decrease, p=0.009). Complication rate of hitting anon-targeted lesion decreased from 11.9% without AR (7/59 needle passes) to 0%with AR (0/27 needle passes). First needle passes were more nearly aligned withthe ideal target trajectory with AR versus without AR (4.6{\deg} vs 8.0{\deg}offset, respectively, p=0.018). Medical students, residents, and attendings allperformed at the same level with AR guidance.  Conclusions: 3D AR guidance can provide significant improvements inprocedural efficiency and radiation dose savings for targeting challenging,out-of-plane lesions. AR guidance elevated the performance of all operators tothe same level irrespective of prior clinical experience.

3D Augmented Reality-Assisted CT-Guided Interventions: System Design and Preclinical Trial on an Abdominal Phantom using HoloLens 2