Complex robotic-enhanced percutaneous coronary intervention

Latest Developments in Robotic Percutaneous Coronary Interventions

Since the first robotic-assisted percutaneous coronary intervention procedure (R-PCI) was performed in 2004, there has been a steady evolution in robotic technology, combined with a growth in the number of robotic installations worldwide and operator experience. This review summarises the latest developments in R-PCI with a focus on developments in robotic technology, procedural complexity, tele-stenting and training methods, which have all contributed to the global expansion in R-PCI.

Robotic Interventional Neuroradiology: Progress, Challenges, and Future Prospects

Advances in robotic technology have improved standard techniques in numerous surgical and endovascular specialties, offering more precision, control, and better patient outcomes. Robotic-assisted interventional neuroradiology is an emerging field at the intersection of interventional neuroradiology and biomedical robotics. Endovascular robotics can automate maneuvers to reduce procedure times and increase its safety, reduce occupational hazards associated with ionizing radiations, and expand networks of care to reduce gaps in geographic access to neurointerventions. To date, many robotic neurointerventional procedures have been successfully performed, including cerebral angiography, intracranial aneurysm embolization, carotid stenting, and epistaxis embolization. This review aims to provide a survey of the state of the art in robotic-assisted interventional neuroradiology, consider their technical and adoption limitations, and explore future developments critical for the widespread adoption of robotic-assisted neurointerventions.

Robots in Healthcare: a Scoping Review

Purpose of Review

Robots are increasingly being adopted in healthcare to carry out various tasks that enhance patient care. This scoping review aims to establish the types of robots being used in healthcare and identify where they are deployed.

Recent Findings

Technological advancements have enabled robots to conduct increasingly varied and complex roles in healthcare. For instance, precision tasks such as improving dexterity following stroke or assisting with percutaneous coronary intervention.

Summary

This review found that robots have played 10 main roles across a variety of clinical environments. The two predominant roles were surgical and rehabilitation and mobility. Although robots were mainly studied in the surgical theatre and rehabilitation unit, other settings ranged from the hospital ward to inpatient pharmacy. Healthcare needs are constantly evolving, as demonstrated by COVID-19, and robots may assist in adapting to these changes. The future will involve increased telepresence and infrastructure systems will have to improve to allow for this.

Supplementary Information

The online version contains supplementary material available at 10.1007/s43154-022-00095-4.

Totally robotic three-vessel percutaneous coronary intervention with total occlusion using robotic automation

Robotic-assisted percutaneous coronary intervention (PCI) has emerged as an alternative to manual PCI to mitigate the risk of occupational hazards for operators, and to increase precision of device placement. Previous studies have reported the safety and efficacy of robotic-assisted PCI in simpler lesions, and recently the safety and efficacy of robotic-assisted chronic total occlusion PCI have been reported. Herein, we report two cases with three-vessel disease, including total occlusions, successfully treated robotically utilizing newer guidewire and device automation.

Safety and feasibility of robotic assisted percutaneous coronary intervention compared to standard percutaneous coronary intervention- a systematic review and meta-analysis

Objective

Robotically assisted PCI offers a great alternative to S–PCI. This has gained even more relevance during the COVID-19 pandemic era however safety of R–PCI compared to S–PCI has not been studied well. This study explores the safety and efficacy of robotically assisted PCI (R–PCI) compared to standard PCI (S–PCI) for the treatment of coronary artery disease (CAD).

Methods

PubMed, Scopus, Ovid, and Google scholar databases were searched for studies comparing R–PCI to S–PCI. Outcomes included clinical success, procedure time, fluoroscopy time, contrast use and radiation exposure.

Results

Theauthors included 5 studies comprising 1555 patients in this meta-analysis. Clinical success was comparable in both arms (p = 0.91). Procedure time was significantly longer in R–PCI group (risk ratio: 5.52, 95% confidence interval: 1.85 to 9.91, p = 0.003). Compared to S–PCI, patients in R–PCI group had lower contrast use (meandifference: −19.88, 95% confidence interval: −21.43 to −18.33, p < 0.001), fluoroscopy time (mean difference:-1.82, 95% confidence interval: −3.64 to −0.00, p = 0.05) and radiation exposure (mean difference:-457.8, 95% confidence interval: −707.14 to −208.14, p < 0.001).

Conclusion

R–PCI can achieve similar success as S–PCI at the expense of longer procedural times. However, radiation exposure and contrast exposure were lower in the R–PCI arm.

Robotic-assisted PCI: The future of coronary intervention?

Robotic percutaneous coronary intervention (R-PCI) is a novel approach to performing percutaneous coronary intervention (PCI) whereby the operator can utilise remotely controlled technology to manipulate guidewires and catheter devices. This enables the procedure to be undertaken from within a radiation-shielded cockpit. Success in early trials has led to the release of commercially available robotic platforms which have now received regulatory approval and are available for use in clinical practice. Recent trials evaluating R-PCI have demonstrated high technical success rates with low complication rates. Despite this, a significant number of cases, particularly those with complex anatomy, still require at least partial conversion to a manual procedure. Advantages of R-PCI include accurate stent placement, reduced operator radiation exposure and a presumed reduction in orthopedic injuries. Limitations include current incompatibility with certain intravascular imaging catheters and the inability to manipulate multiple guidewires and stents simultaneously. Patients presenting with ST-elevation myocardial infarction requiring primary-PCI have also largely been excluded from existing R-PCI studies. Given these caveats, R-PCI remains a novel technology and has yet to become commonplace in cardiac catheterisation laboratories, however with increasing safety and feasibility data emerging, it is possible that R-PCI may form part of standard practice in the future.

Iterative Improvement and Marginal Gains in Coronary Revascularisation: Is Robot-assisted Percutaneous Coronary Intervention the New Hope?

Percutaneous coronary intervention (PCI) has undergone a rapid and adaptive evolution since its introduction into clinical practice more than 40 years ago. It is the most common mode of coronary revascularisation in use, with the scope, breadth and constellation of disease being treated increasing markedly over time. This has principally been driven by improvements in technology, engineering and training in the field, which has facilitated more complex PCI procedures to be undertaken safely. Robot-assisted PCI represents the next paradigm shift in contemporary PCI practice. It has the ability to enhance procedural accuracy for the patient while improving radiation safety and ergonomics for the operator. This state-of-the-art review outlines the current position and future potential of robot-assisted PCI.

Robotic-Assisted Percutaneous Coronary Intervention Through Transradial Approach: Experience in 4 Patients with Complex Lesions

Robotic-assisted percutaneous coronary intervention can reduce the exposure of interventional cardiologists to radiation and minimize the risk of occupational orthopedic injuries from wearing heavy protective aprons. The PRECISE (Percutaneous Robotically-Enhanced Coronary Intervention) study showed the efficacy and safety of robotic-assisted procedures for relatively low-risk lesions in single coronary arteries. Several reports have described robotic-assisted treatment of complex high-risk lesions, mostly through the transfemoral approach. We report 4 cases of patients in whom we used the transradial approach to treat complex lesions in the left anterior descending coronary artery with bifurcation balloon angioplasty reconstruction (2 cases), in the ostium of the first diagonal branch, and in the right coronary artery.

Hybrid Robotic Impella-Assisted Single Arterial Access ComplexHigh-Risk Percutaneous Coronary Intervention

Robotic-assisted percutaneous coronary intervention (PCI) has become popular among operators due to substantial reduction in radiation dose. Complex coronary intervention often requires mechanical support and have long fluoroscopy time. Robotic PCI offers an elegant solution by reducing operator fatigue and offering better analysis in the robotic console. We report a hybrid robotic impella assisted single arterial access complex high-risk PCI to the left anterior descending artery via the left internal mammary artery.

Initial report of safety and procedure duration of robotic-assisted chronic total occlusion coronary intervention

BACKGROUND

No previous reports have examined the impact of robotic-assisted (RA) chronic total occlusion (CTO) PCI on procedural duration or safety compared to totally manual CTO PCI.

METHODS

Among 95 patients who underwent successful PCI of a single CTO lesion at two centers, 49 (52%) were performed RA and were performed 46 (48%) totally manually. Cockpit time was the time the primary operator entered to robotic cockpit until the procedure was complete. "Theoretical" cockpit time in the control group was time the primary operator would have entered the cockpit after lesion crossing until the procedure was complete. Major adverse events (MAEs) were the composite of death, myocardial infarction, clinical perforation, significant vessel dissection, arrhythmia, acute thrombosis, and stroke.

RESULTS

The lesion characteristics, procedural time, and contrast dose were similar. All procedures except for one (2%) selected for robotic completion after lesion crossing were completed successfully. The frequency of MAE was similar between groups and there were no in-hospital deaths. The cockpit time was 8 min longer in RA CTO PCI than the theoretical cockpit time in totally manual CTO PCI (40.6 ± 12.7 vs. 32.1 ± 17.8, p < .01).

CONCLUSION

RA CTO PCI was not associated with excess adverse events compared with totally manual CTO PCI and resulted in an average 41 min cockpit time equaling to 48% of procedure time without radiation exposure or requirement for the primary operator to wear a lead apron. Understanding the relationship between cockpit time and reductions in radiation exposure and lead apron-related orthopedic complications for operators requires future study.

Cath Lab Robotics: Paradigm Change in Interventional Cardiology?

PURPOSE OF REVIEW

To review the contemporary evidence for robotic-assisted percutaneous coronary and vascular interventions, discussing its current capabilities, limitations, and potential future applications.

RECENT FINDINGS

Robotic-assisted cardiovascular interventions significantly reduce radiation exposure and orthopedic strains for interventionalists, while maintaining high rates of device and clinical success. The PRECISE and CORA-PCI studies demonstrated the safety and efficacy of robotic-assisted percutaneous coronary intervention (PCI) in increasingly complex coronary lesions. The RAPID study demonstrated similar findings in peripheral vascular interventions (PVI). Subsequent studies have demonstrated the safety and efficacy of second-generation devices, with automations mimicking manual PCI techniques. While innovations such as telestenting continue to bring excitement to the field, major limitations remain-particularly the lack of randomized trials comparing robotic-assisted PCI with manual PCI. Robotic technology has successfully been applied to multiple cardiovascular procedures. There are limited data to evaluate outcomes with robotic-assisted PCI and other robotic-assisted cardiovascular procedures, but existing data show some promise of improving the precision of PCI while decreasing occupational hazards associated with radiation exposure.

Robotic-Assisted Percutaneous Coronary Intervention: Concept, Data, and Clinical Application

The occupational hazards for interventional cardiologists include the risk of cataracts, malignancy, and orthopedic injury. Robotic technology is now available with the introduction of platforms for performing percutaneous coronary and peripheral interventions. The original remote navigation system has evolved into the current CorPath robotic system, now approved for robotic-assisted cardiovascular interventions. The system removes the operator from the tableside and has been validated for safety, feasibility, and efficacy in coronary and peripheral vascular disease.

Overlapping radiofrequency ablation planning and robot-assisted needle insertion for large liver tumors

BACKGROUND

We aimed at facilitating percutaneous radiofrequency ablation (RFA) for large tumors with accurate overlapping ablation planning and robot-assisted needle insertion from a single incision port (SIP).

METHODS

We developed a personalized and quantitative RFA planning method to obtain multiple needle overlapping ablation planning through a single incision. A robot with a remote center of motion mechanism was designed to perform needle insertions through a SIP according to the planning.

RESULTS

Numerical and visual evaluation showed that the planning could yield nearly full coverage over large tumors and greatly reduce both ablation times and the ablations of normal tissues. Ex vivo and in vivo experiments showed that our robot-assisted needle insertion system was capable of conducting the RFA procedure in large liver tumors from a SIP.

CONCLUSIONS

Robot-assisted RFA needle insertions from a SIP makes RFA treatment for large tumors more minimally invasive, predictable, and repeatable.

Robotically-assisted percutaneous coronary intervention: Reasons for partial manual assistance or manual conversion

BACKGROUND

Robotically-assisted percutaneous coronary intervention (R-PCI) is feasible for simple coronary lesions.

OBJECTIVES

To determine the frequency and reasons for partial manual assistance or manual conversion during R-PCI in clinical practice.

METHODS

The CorPath 200 System (Corindus, Waltham, MA) enables the operator to sit in a radiation-shielded cockpit and remotely control intracoronary devices including guidewires, balloons, and stents. Consecutive R-PCI procedures performed over 18months were analyzed to identify reasons for planned or unplanned manual assistance or manual conversion, and categorized as due to 1) adverse event; 2) technical limitation of the robotic platform; or 3) limited guide catheter/wire support.

RESULTS

During the study period, 108 R-PCI procedures (68.1±11.0years, 77.8% men, 69.4% elective PCI, 78.3% type B2/C lesions, and 50.3% left anterior descending/left main target lesion segment) were performed. High robotic technical success (91.7%) and clinical procedural success (99.1%) were achieved. Twenty procedures (18.5%) required either planned partial manual assistance (3.7%), unplanned partial manual assistance (7.4%), or manual conversion (7.4%). Among these procedures, manual assistance/conversion was required in 3 procedures for an adverse event (15%), 8 for technical limitation of the robotic platform (40%), and 9 for guide catheter/wire support issues (45%).

CONCLUSIONS

High clinical success with R-PCI for a complex lesion cohort is possible with only occasional partial manual assistance or manual conversion. The majority of procedures requiring manual assistance/conversion were due to limited guide catheter/wire support or robotic platform limitations, rather than occurrence of adverse events.

Robotics in percutaneous cardiovascular interventions

INTRODUCTION

The fundamental technique of performing percutaneous cardiovascular (CV) interventions has remained unchanged and requires operators to wear heavy lead aprons to minimize exposure to ionizing radiation. Robotic technology is now being utilized in interventional cardiology partially as a direct result of the increasing appreciation of the long-term occupational hazards of the field. This review was undertaken to report the clinical outcomes of percutaneous robotic coronary and peripheral vascular interventions. Areas covered: A systematic literature review of percutaneous robotic CV interventions was undertaken. The safety and feasibility of percutaneous robotically-assisted CV interventions has been validated in simple to complex coronary disease, and iliofemoral disease. Studies have shown that robotically-assisted PCI significantly reduces operator exposure to harmful ionizing radiation without compromising procedural success or clinical efficacy. In addition to the operator benefits, robotically-assisted intervention has the potential for patient advantages by allowing more accurate lesion length measurement, precise stent placement and lower patient radiation exposure. However, further investigation is required to fully elucidate these potential benefits. Expert commentary: Incremental improvement in robotic technology and telecommunications would enable treatment of an even broader patient population, and potentially provide remote robotic PCI.

The Development of Robotic Technology in Cardiac and Vascular Interventions

Robotic technology has been used in cardiovascular medicine for over a decade, and over that period its use has been expanded to interventional cardiology and percutaneous coronary and peripheral vascular interventions. The safety and feasibility of robotically assisted interventions has been demonstrated in multiple studies ranging from simple to complex coronary lesions, and in the treatment of iliofemoral and infrapopliteal disease. These studies have shown a reduction in operator exposure to harmful ionizing radiation, and the use of robotics has the intuitive benefit of alleviating the occupational hazard of operator orthopedic injuries. In addition to the interventional operator benefits, robotically assisted intervention has the potential to also be beneficial for patients by allowing more accurate lesion length measurement, stent placement, and patient radiation exposure; however, more investigation is required to elucidate these benefits fully.

Robotic-assisted thermal ablation of liver tumours

OBJECTIVE

This study aimed to assess the technical success, radiation dose, safety and performance level of liver thermal ablation using a computed tomography (CT)-guided robotic positioning system.

METHODS

Radiofrequency and microwave ablation of liver tumours were performed on 20 patients (40 lesions) with the assistance of a CT-guided robotic positioning system. The accuracy of probe placement, number of readjustments and total radiation dose to each patient were recorded. The performance level was evaluated on a five-point scale (5-1: excellent-poor). The radiation doses were compared against 30 patients with 48 lesions (control) treated without robotic assistance.

RESULTS

Thermal ablation was successfully completed in 20 patients with 40 lesions and confirmed on multiphasic contrast-enhanced CT. No procedure related complications were noted in this study. The average number of needle readjustment was 0.8 ± 0.8. The total CT dose (DLP) for the entire robotic assisted thermal ablation was 1382 ± 536 mGy.cm, while the CT fluoroscopic dose (DLP) per lesion was 352 ± 228 mGy.cm. There was no statistically significant (p > 0.05) dose reduction found between the robotic-assisted versus the conventional method.

CONCLUSION

This study revealed that robotic-assisted planning and needle placement appears to be safe, with high accuracy and a comparable radiation dose to patients.

KEY POINTS

• Clinical experience on liver thermal ablation using CT-guided robotic system is reported. • The technical success, radiation dose, safety and performance level were assessed. • Thermal ablations were successfully performed, with an average performance score of 4.4/5.0. • Robotic-assisted ablation can potentially increase capabilities of less skilled interventional radiologists. • Cost-effectiveness needs to be proven in further studies.