Current State of Robotics in Interventional Radiology

Paranoid About Androids: A Review of Robotics in Radiology

In tandem with the ever-increasing global population, the demand for diagnostic radiology service provision is on the rise and at a disproportionate rate compared to the number of radiologists available to practice. The current "revolution in robotics" promises to alleviate personnel shortages in many sectors of industry, including medicine. Despite negative depictions of robots in popular culture, their multiple potential benefits cannot be overlooked, in particular when it comes to health service provision. The type of robots used for interventional procedures are largely robotic-assistance devices, such as the Da Vinci surgical robot. Advances have also been made with regards to robots for image-guided percutaneous needle placement, which have demonstrated superior accuracy compared to manual methods. It is likely that artificial intelligence will come to play a key role in the field of robotics and will result in an increase in the levels of robotic autonomy attainable. However, this concept is not without ethical and legal considerations, most notably who is responsible should an error occur; the physician, the robot manufacturer, software engineers, or the robot itself? Efforts have been made to legislate in order to protect against the potentially harmful effects of unexplainable "black-box" decision outputs of artificial intelligence systems. In order to be accepted by patients, studies have shown that the perceived level of trustworthiness and predictability of robots is crucial. Ultimately, effective, widespread implementation of medical robotic systems will be contingent on developers remaining cognizant of factors that increase human acceptance, as well as ensuring compliance with regulations.

The Transformative Impact of AI, Extended Reality, and Robotics in Interventional Radiology: Current Trends and Applications

Interventional Radiology is at the forefront of integrating advanced imaging techniques and minimally-invasive procedures to enhance patient care. The advent of Digital Health Technologies (DHTs), including artificial intelligence (AI), robotics, and extended reality (XR), is revolutionizing healthcare, particularly in IR due to its reliance on innovative technology and advanced imaging. Since 2016, the proportion of these DHT-related publications in IR has consistently increased. The proportion of AI-related studies published in IR was 69% higher than in surgery, XR-related studies were 94% higher, and robotics studies were 192% higher, indicating a more rapid growth rate in IR compared to surgery. This article explores the transformative impact of these technologies on IR, emphasizing their potential to enhance precision, efficiency, and patient outcomes. Despite the promising advancements, there is a lack of standardization and clinical consensus on the optimal use of DHTs in IR. The variability in IR procedures and imaging systems across hospitals complicates the standardization of workflows and comparison of studies. This underscores the importance of integrating DHTs as aids to IR practitioners rather than replacement, ensuring that these technologies enhance both clinical and procedural practice.

Fluoroscopy and Cone Beam CT Guidance in Robotic Interventions

Developments in robotic interventions have greatly affected the field of interventional radiology (IR), particularly when combined with imaging modalities such as fluoroscopy and cone-beam computed tomography (CBCT). The aim of this review is to compare and evaluate the safety, precision, and clinical outcomes of fluoroscopy and CBCT-guided robotic interventions in IR. An extensive search of the literature on PubMed and Google Scholar databases was conducted up to November 2024. Searched terms included "robotic interventions," "fluoroscopy guidance," "cone-beam CT guidance," and "robotic surgery." Literature review showed improved patient outcomes in robotic-assisted procedures, with fewer complications and higher success rates especially in anatomically challenging cases. Fluoroscopy-guided robotic interventions provide real-time imaging, allowing for accurate interventions while CBCT-guided procedures offer enhanced 3D visualization, reducing radiation exposure while maintaining high diagnostic accuracy and shorter needle puncture times. Both fluoroscopy and CBCT-guided robotic interventions play a critical role in advancing interventional radiology and are expected to improve procedural outcomes in IR.

Components of Robotic Systems in Image-Guided Percutaneous Interventions

The field of interventional radiology is facing a growing demand for percutaneous procedures targeting smaller and more complex lesions. Percutaneous medical robots have proven to increase efficiency and accuracy and can address these issues. This review is intended to provide an overview of the functionality and components of these robotic systems for operators learning to use them. We begin by discussing the functions of robots in percutaneous interventions and how they operate. After this discussion, greater focus is then placed on the technical components of robots which help achieve these functions.

Tracking and Navigation Technologies for Image-Guided Trans-Arterial Interventions

Trans-arterial interventions are an increasingly utilized approach for diagnosing and treating a wide range of pathologies, providing superior patient outcomes compared to traditional open surgical methods. Recent advancements in tracking and navigation technologies have significantly refined these interventions, enhancing procedural precision and success. Advanced imaging modalities, such as fluoroscopy, cone beam computed tomography (CBCT), and intravascular ultrasound (IVUS), are frequently used strategies offering critical real-time guidance. Although fluoroscopy remains the primary choice for many procedures, advancements in CBCT and IVUS have enabled the delivery of detailed volumetric and intravascular imaging while reducing radiation exposure. Aiming to enhance imaging capabilities further, image fusion and augmented reality technologies show substantial potential for integrating multiple datasets into cohesive models, improving instrument tracking and spatial orientation during interventions. Innovations in navigation systems, including electromagnetic, fiberoptic, and robotic navigation, provide additional tracking capabilities for enhanced intra-arterial navigation. This article will review the current advancements in imaging, tracking, navigation, and image fusion technologies and explore their utility in enhancing trans-arterial interventions.

Remote-Controlled and Teleoperated Systems: Taking Robotic Image Guided Interventions to the Next Stage

Remote-controlled and teleoperated robotic systems mark transformative advancements in interventional radiology (IR), with the potential to enhance precision, reduce radiation exposure, and expand access to care. By integrating robotic devices with imaging guidance, these systems enable precise instrument placement and navigation, thereby improving the efficacy and safety of minimally invasive procedures. Remote-controlled and teleoperated robotic systems-operated by clinicians using control interfaces from within or adjacent to the procedure room-are being adopted for both percutaneous and endovascular interventions. In contrast, although their application is still experimental, teleoperation over long distances hold promise for extending IR services to medically underserved areas by enabling remote procedures. This review details the definitions and components of remote-controlled and teleoperated robotic systems in IR, examines their clinical applications in percutaneous and endovascular interventions, and discusses relevant challenges and future directions for their incorporation into IR practices.

Robot-Assisted 2D Fluoroscopic Needle Placement-A Phantom Study

RATIONALE AND OBJECTIVES

To evaluate the targeting accuracy of a novel robot-assisted guidance technique relying on one pair of 2D C-arm images.

MATERIAL AND METHODS

In total, 160 punctures were carried out semi-automatically by using a novel robotic device. The needle's paths were planned based on one pair of 2D fluoroscopic images from different angles. Conically shaped aluminum tips inside a gelatin-filled plexiglass phantom served as targets. The accuracy of the needle placement was assessed by taking control CTs and measuring the Euclidean distance (ED) and normal distance (ND) between the needle and the target point. In addition, the procedural time per needle placement was evaluated.

RESULTS

The accomplished mean NDs at the target for the 45°, 60°, 75° and 90° angles were 1.86 mm (SD ± 0.19), 2.68 mm (SD ± 0.18), 2.19 mm (SD ± 0.18) and 1.86 mm (SD ± 0.18), respectively. The corresponding mean EDs were 2.32 mm (SD ± 0.16), 2.68 mm (SD ± 0.18), 2.65 mm (SD ± 0.16) and 2.44 mm (SD ± 0.15). The mean duration of the total procedure, including image acquisition, trajectory planning and placement of four needles sequentially, was 12.7 min.

CONCLUSIONS

Robotic guidance based on two 2D fluoroscopy images allows for the precise placement of needle-like instruments at the first attempt without the need for using an invasive dynamic reference frame. This novel approach seems to be a valuable tool for the precise targeting of various anatomical structures that can be identified in fluoroscopic images.

Robotic-Assisted Endovascular Treatment for Transplant Renal Artery Stenosis: A Feasibility Study

PURPOSE

To describe a single-center experience with robotic-assisted endovascular treatment for transplant renal artery stenosis.

MATERIALS AND METHODS

This is a single-center, retrospective, feasibility study of 4 consecutive cases of robotic-assisted endovascular surgery for transplant renal artery stenosis from October 2021 to August 2022.

RESULTS

All lesions were identified, and stenting was performed with no complications. Conversion to manual control was not necessary. The mean fluoroscopy time was 25.25 min (range 12-60.9). A control Doppler ultrasound was routinely performed, demonstrating no residual lesions in all cases. There was no reintervention during the follow-up period. The operator learning curve was felt to be acceptable.

CONCLUSION

Robotic-assisted endovascular treatment is a feasible technique for transplant renal artery stenosis.

How AI and Robotics Will Advance Interventional Radiology: Narrative Review and Future Perspectives

The rapid advancement of artificial intelligence (AI) and robotics has led to significant progress in various medical fields including interventional radiology (IR). This review focuses on the research progress and applications of AI and robotics in IR, including deep learning (DL), machine learning (ML), and convolutional neural networks (CNNs) across specialties such as oncology, neurology, and cardiology, aiming to explore potential directions in future interventional treatments. To ensure the breadth and depth of this review, we implemented a systematic literature search strategy, selecting research published within the last five years. We conducted searches in databases such as PubMed and Google Scholar to find relevant literature. Special emphasis was placed on selecting large-scale studies to ensure the comprehensiveness and reliability of the results. This review summarizes the latest research directions and developments, ultimately analyzing their corresponding potential and limitations. It furnishes essential information and insights for researchers, clinicians, and policymakers, potentially propelling advancements and innovations within the domains of AI and IR. Finally, our findings indicate that although AI and robotics technologies are not yet widely applied in clinical settings, they are evolving across multiple aspects and are expected to significantly improve the processes and efficacy of interventional treatments.

Puncture Accuracy of Robot-Assisted CT-Based Punctures in Interventional Radiology: An Ex Vivo Study

OBJECTIVES

The purpose of this study was to assess the performance of an optically tracked robot for computed-tomography (CT)-guided needle placements in a phantom study.

METHODS

In total, 240 needle punctures were carried out with the help of an optically tracked robotic device (Micromate) based on CT image datasets at three different slice thicknesses (1, 3, and 5 mm). Conically shaped targets inside a gelatin-filled plexiglass phantom were punctured. The target positioning error between the planned and actual needle trajectory was assessed by measuring the lateral positioning error (ND) between the target and the puncture needle and the Euclidean distance (ED) between the needle tip and target in control CTs.

RESULTS

The mean ND and ED for the thinnest CT slice thickness were 1.34 mm (SD ± 0.82) and 2.1 mm (SD ± 0.75), respectively. There was no significant impact of target depth on targeting accuracy for ND (p = 0.094) or ED (p = 0.187). The mean duration for the planning of one trajectory and for needle positioning were 42 s (SD ± 4) and 64 s (SD ± 7), respectively.

CONCLUSIONS

In this ex vivo study, the robotic targeting device yielded satisfactory accuracy results at CT slice thicknesses of 1 and 3 mm. This technology may be particularly useful in interventions where the accurate placement of needle-like instruments is required.

Evolutionary trends and innovations in cardiovascular intervention

Cardiovascular diseases remain a global health challenge, prompting continuous innovation in medical technology, particularly in Cardiovascular MedTech. This article provides a comprehensive exploration of the transformative landscape of Cardiovascular MedTech in the 21st century, focusing on interventions. The escalating prevalence of cardiovascular diseases and the demand for personalized care drive the evolving landscape, with technologies like wearables and AI reshaping patient-centric healthcare. Wearable devices offer real-time monitoring, enhancing procedural precision and patient outcomes. AI facilitates risk assessment and personalized treatment strategies, revolutionizing intervention precision. Minimally invasive procedures, aided by robotics and novel materials, minimize patient impact and improve outcomes. 3D printing enables patient-specific implants, while regenerative medicine promises cardiac regeneration. Augmented reality headsets empower surgeons during procedures, enhancing precision and awareness. Novel materials and radiation reduction techniques further optimize interventions, prioritizing patient safety. Data security measures ensure patient privacy in the era of connected healthcare. Modern technologies enhance traditional surgeries, refining outcomes. The integration of these innovations promises to shape a healthier future for cardiovascular procedures, emphasizing collaboration and research to maximize their transformative potential.

Performance Evaluation of a Miniature and Disposable Endovascular Robotic Device

PURPOSE

The LIBERTY® Robotic System is a miniature, single-use device designed to facilitate remote-controlled navigation to intravascular targets. We aim to evaluate the robot's performance to manipulate a range of microguidewires and microcatheters during percutaneous endovascular procedures.

MATERIALS AND METHODS

Six interventional radiologists performed selective robotic-assisted catheterization of eight pre-determined vascular targets in a pig model. The navigation time from the guiding catheter tip to the target vessel was recorded. Each physician with a clinical experience of 20 years completed a questionnaire to evaluate the ease of use, accuracy, and safety of the robotic operation.

RESULTS

Most of the physicians reached the vascular targets in less than one minute. There was no angiographic evidence of vascular injury such as artery laceration or contusion. All physicians reported consensus about the high performance of the robot.

CONCLUSION

The miniature disposable robot is effective at reaching a range of vessels in a porcine model. Physicians found the device intuitive and easy to operate remotely.

Safety and feasibility study of a novel robotic system in an in vivo porcine vascular model

PURPOSE

The goal of this preclinical study is to assess the functionality, technical feasibility, and safety of a new vascular robotic LIBERTYR 3 System, in the microcatheterization of vascular targets using a range of guidewires and microcatheters.

MATERIAL AND METHODS

An anesthetized pig served as an arterial model for the robotic device (LIBERTYR3; Microbot Medical Ltd, Yoqneam, IL). The primary efficacy endpoint was the evaluation of its capability to selectively catheterize predetermined distal arterial branches in the liver, kidneys, and mesenteric arteries (technical success), under fluoroscopy guidance. The primary safety endpoint was the occurrence of angiographic acute catheterization-related complications (dissection, thrombosis, embolism, perforation). The catheterizations were conducted by two interventional radiologists that present different work experience in endovascular procedures (18 and 2 years respectively), using a variety of microcatheters and wires. Various procedural parameters such as functionality, practicality, ease of use, and time required for selective catheterization, were evaluated, and recorded.

RESULTS

All pre-determined arteries were successfully selectively catheterized (100% technical success), by both operators. No angiographic acute complications occurred. The microcatheters and wires were manipulated using the remote portable console in an effortless manner that maintained a high level of accuracy. Mean time for selective catheterization was 131 ± 82 s. The robot's conversion function to manual operation was successfully demonstrated.

CONCLUSION

Robotic navigation and catheterization of selected target arteries were accomplished without observable vascular damage, suggesting that the LIBERTYR 3 robotic system is a reliable and safe tool for robotic-assisted endovascular navigation. Further experimental studies are required to evaluate safety and efficacy prior to introduction into clinical practice.

Navigation and Robotics in Interventional Oncology: Current Status and Future Roadmap

Interventional oncology (IO) is the field of Interventional Radiology that provides minimally invasive procedures under imaging guidance for the diagnosis and treatment of malignant tumors. Sophisticated devices can be utilized to increase standardization, accuracy, outcomes, and "repeatability" in performing percutaneous Interventional Oncology techniques. These technologies can reduce variability, reduce human error, and outperform human hand-to-eye coordination and spatial relations, thus potentially normalizing an otherwise broad diversity of IO techniques, impacting simulation, training, navigation, outcomes, and performance, as well as verification of desired minimum ablation margin or other measures of successful procedures. Stereotactic navigation and robotic systems may yield specific advantages, such as the potential to reduce procedure duration and ionizing radiation exposure during the procedure and, at the same time, increase accuracy. Enhanced accuracy, in turn, is linked to improved outcomes in many clinical scenarios. The present review focuses on the current role of percutaneous navigation systems and robotics in diagnostic and therapeutic Interventional Oncology procedures. The currently available alternatives are presented, including their potential impact on clinical practice as reflected in the peer-reviewed medical literature. A review of such data may inform wiser investment of time and resources toward the most impactful IR/IO applications of robotics and navigation to both standardize and address unmet clinical needs.

Overcoming Barriers and Advancements in Endovascular Robotics: A Review of Systems and Developments

Endovascular robots have the potential to revolutionize the field of vascular interventions by enhancing procedural efficiency, accuracy, and standardization. They aim to reduce radiation exposure, as well as physical strain on operators and medical staff, while enabling precise navigation of catheters through challenging anatomical structures. However, the widespread adoption of these robots faces barriers, such as real estate constraints, setup time, limited range of compatible tools, and high costs. This paper discusses these barriers and highlights Hansen Medical's Magellan and the Liberty robotic systems as notable examples. New developments will offer cost-effective, intuitive, and disposable approaches to endovascular procedures. Despite challenges, endovascular robots hold promise for improving access to endovascular therapy and transforming patient care in various healthcare settings.

Neuroendovascular Surgery Applications in Craniocervical Trauma

Cerebrovascular injuries resulting from blunt or penetrating trauma to the head and neck often lead to local hemorrhage and stroke. These injuries present with a wide range of manifestations, including carotid or vertebral artery dissection, pseudoaneurysm, occlusion, transection, arteriovenous fistula, carotid-cavernous fistula, epistaxis, venous sinus thrombosis, and subdural hematoma. A selective review of the literature from 1989 to 2023 was conducted to explore various neuroendovascular surgical techniques for craniocervical trauma. A PubMed search was performed using these terms: endovascular, trauma, dissection, blunt cerebrovascular injury, pseudoaneurysm, occlusion, transection, vasospasm, carotid-cavernous fistula, arteriovenous fistula, epistaxis, cerebral venous sinus thrombosis, subdural hematoma, and middle meningeal artery embolization. An increasing array of neuroendovascular procedures are currently available to treat these traumatic injuries. Coils, liquid embolics (onyx or n-butyl cyanoacrylate), and polyvinyl alcohol particles can be used to embolize lesions, while stents, mechanical thrombectomy employing stent-retrievers or aspiration catheters, and balloon occlusion tests and super selective angiography offer additional treatment options based on the specific case. Neuroendovascular techniques prove valuable when surgical options are limited, although comparative data with surgical techniques in trauma cases is limited. Further research is needed to assess the efficacy and outcomes associated with these interventions.