Long Distance Tele-Robotic-Assisted Percutaneous Coronary Intervention: A Report of First-in-Human Experience

Perspectives on Remote Robotic-Assisted Stroke Treatment: A Commentary Paper

The proved feasibility of robotic-assisted endovascular treatment of intracranial aneurysms has stimulated the idea of a potential application of remote robotics for the treatment of acute ischemic stroke. The possibility of developing a more advanced remote-controlled robotic system capable of performing a complete mechanical thrombectomy procedure would help bridge the health care gap of lack of technical expertise in isolated areas. This possibility could allow a more equitable access to mechanical thrombectomy to a larger number of patients and be a breakthrough for acute ischemic stroke care worldwide. Many aspects around the technical, human, financial, and regulatory requirements should be discussed to implement remote robotic-assisted procedures. In this State of Practice article, we aimed to outline the major challenges that must be considered, as well as proposed solutions. However, different solutions may be applied in different health care systems on the basis of the availability of human and financial resources.

Evaluation of Robotic-Assisted Carotid Artery Stenting in a Virtual Model Using Motion-Based Performance Metrics

PURPOSE

Robotic-assisted carotid artery stenting (CAS) cases have been demonstrated with promising results. However, no quantitative measurements have been made to compare manual with robotic-assisted CAS. This study aims to quantify surgical performance using tool tip kinematic data and metrics of precision during CAS with manual and robotic control in an ex vivo model.

MATERIALS AND METHODS

Transfemoral CAS cases were performed in a high-fidelity endovascular simulator. Participants completed cases with manual and robotic techniques in 2 different carotid anatomies in random order. C-arm angulations, table position, and endovascular devices were standardized. Endovascular tool tip kinematic data were extracted. We calculated the spectral arc length (SPARC), average velocity, and idle time during navigation in the common carotid artery and lesion crossing. Procedural time, fluoroscopy time, movements of the deployed filter wire, precision of stent, and balloon positioning were recorded. Data were analyzed and compared between the 2 modalities.

RESULTS

Ten participants performed 40 CAS cases with a procedural success of 100% and 0% residual stenosis. The median procedural time was significantly higher during the robotic-assisted cases (seconds, median [interquartile range, IQR]: 128 [49.5] and 161.5 [62.5], p=0.02). Fluoroscopy time differed significantly between manual and robotic-assisted procedures (seconds, median [IQR]: 81.5 [32] and 98.5 [39.5], p=0.1). Movement of the deployed filter wire did not show significant difference between manual and robotic interventions (mm, median [IQR]: 13 [10.5] and 12.5 [11], p=0.5). The postdilation balloon exceeded the margin of the stent with a median of 2 [1] mm in both groups. Navigation with robotic assistance showed significantly lower SPARC values (-5.78±3.14 and -8.63±3.98, p=0.04) and higher idle time values (8.92±8.71 and 3.47±3.9, p=0.02) than those performed manually.

CONCLUSIONS

Robotic-assisted and manual CAS cases are comparable in the precision of stent and balloon positioning. Navigation in the carotid artery is associated with smoother motion and higher idle time values. These findings highlight the accuracy and the motion stabilizing capability of the endovascular robotic system.

CLINICAL IMPACT

Robotic assistance in the treatment of peripheral vascular disease is an emerging field and may be a tool for radiation protection and the geographic distribution of endovascular interventions in the future. This preclinical study compares the characteristics of manual and robotic-assisted carotid stenting (CAS). Our results highlight, that robotic-assisted CAS is associated with precise navigation and device positioning, and smoother navigation compared to manual CAS.

Robotic Assisted Percutaneous Coronary Intervention: Initial Australian Experience

BACKGROUND & AIM

Robotic-assisted percutaneous coronary intervention (R-PCI) has been increasingly performed overseas. Initial observations have demonstrated its clinical efficacy and safety with additional potential benefits of more accurate lesion assessment and stent deployment, with reduced radiation exposure to operators and patients. However, data from randomised controlled trials or clinical experience from Australia are lacking.

METHODS

This was a single-centre experience of all patients undergoing R-PCI as part of the run-in phase for an upcoming randomised clinical trial (ACTRN12623000480684). All R-PCI procedures were performed using the CorPath GRX robot (Corindus Vascular Robotics, Waltham, Massachusetts, USA). Key inclusion criteria included patients with obstructive coronary disease requiring percutaneous coronary intervention. Major exclusion criteria included ST-elevation myocardial infarction, cardiogenic shock or lesions deemed unsuitable for R-PCI by the operator. Clinical success was defined as residual stenosis <30% without in-hospital major adverse cardiovascular events (MACE). Technical success was defined as the completion of the R-PCI procedure without unplanned manual conversion. Procedural characteristics were compared between early (cases 1-3) and later (cases 4-21) cases.

RESULTS

Twenty-one (21) patients with a total of 24 lesions were analysed. The mean age of patients was 66.5 years, and 66% of cases were male. Radial access was used in 18 cases (86%). Most lesions were American Heart Association/American College of Cardiology class B2/C (66%). Clinical success was achieved in 100% with manual conversion required in four cases (19%). No procedural complications or in-hospital MACE occurred. Compared to the early cases, later cases had a statistically significantly shorter fluoroscopy time (44.0mins vs 25.2mins, p<0.007), dose area product (967.3 dGy.cm2 vs 361.0dGy.cm2, p=0.01) and air kerma (2484.3mGy vs 797.4mGy, p=0.009) with no difference in contrast usage (136.7mL vs 131.4mL, p=0.88).

CONCLUSIONS

We present the first clinical experience of R-PCI in Australia using the Corindus CorPath GRX robot. We achieved clinical success in all patients and technical success in the majority of cases with no procedural complications or in-hospital MACE. With increasing operator and staff experience, cases required shorter fluoroscopy time and less radiation exposure but similar contrast usage.

Robotically assisted deployment of flow diverter stents for the treatment of cerebral and cervical aneurysms

BACKGROUND

Despite the growing sophistication of robot-assisted surgery, it is necessary to demonstrate that robots can reliably perform complex procedures on site and then remotely. Although a flow diverter stent is one of the most effective and widely used devices, its placement is sometimes challenging.

OBJECTIVE

To evaluate the feasibility and safety of the CorPath GRX robotic platform for the embolization of cerebral and cervical aneurysms using flow diverter stents.

METHODS

We performed a single-center technical study of the first 10 flow diverter stent deployments with the CorPath GRX Robotic System (Corindus Inc, Waltham, Massachusetts, USA) for the treatment of cerebral aneurysms between April and October 2022.

RESULTS

Ten patients underwent robot-assisted embolization with flow diverter stents: there were nine intracranial aneurysms (paraclinoid n=6; posterior communicating artery aneurysm n=1; anterior communicating artery n=2) and one cervical aneurysm. Four procedures were performed with coils plus a flow diverter stent, one was performed with woven endobridge plus a flow diverter stent and four were performed with flow diverter stents alone. Of these procedures, two were performed with telescoping flow diverters.All flow diverter stents were deployed with robotic assistance, with only one partial conversion to a manual technique (caused by guidewire torquability limitations). No perioperative complications were observed.

CONCLUSION

Robot-assisted flow diverter stent deployment using the CorPath GRX platform is feasible and appears to be safe. Larger, in-depth studies of the technique's safety and benefits are now warranted.

Technical and ethical considerations in telesurgery

Telesurgery, a cutting-edge field at the intersection of medicine and technology, holds immense promise for enhancing surgical capabilities, extending medical care, and improving patient outcomes. In this scenario, this article explores the landscape of technical and ethical considerations that highlight the advancement and adoption of telesurgery. Network considerations are crucial for ensuring seamless and low-latency communication between remote surgeons and robotic systems, while technical challenges encompass system reliability, latency reduction, and the integration of emerging technologies like artificial intelligence and 5G networks. Therefore, this article also explores the critical role of network infrastructure, highlighting the necessity for low-latency, high-bandwidth, secure and private connections to ensure patient safety and surgical precision. Moreover, ethical considerations in telesurgery include patient consent, data security, and the potential for remote surgical interventions to distance surgeons from their patients. Legal and regulatory frameworks require refinement to accommodate the unique aspects of telesurgery, including liability, licensure, and reimbursement. Our article presents a comprehensive analysis of the current state of telesurgery technology and its potential while critically examining the challenges that must be navigated for its widespread adoption.

Telestroke network to robotic telestroke network: How to upgrade regional stroke care to include remote robotics?

Objective

Selected patients with large vessel occlusion (LVO) strokes can benefit from endovascular therapy (EVT). However, the effectiveness of EVT is largely dependent on how quickly the patient receives treatment. Recent technological developments have led to the first neurointerventional treatments using robotic assistance, opening up the possibility of performing remote stroke interventions. Existing telestroke networks provide acute stroke care, including remote administration of intravenous thrombolysis (IVT). Therefore, the introduction of remote EVT in distant stroke centers requires an adaptation of the existing telestroke networks. The aim of this work was to propose a framework for centers that are potential candidates for telerobotics according to the resources currently available in these centers.

Methods

In this paper, we highlight the future challenges for including remote robotics in telestroke networks. A literature review provides potential solutions.

Results

Existing telestroke networks need to determine which centers to prioritize for remote robotic technologies based on objective criteria and cost-effectiveness analysis. Organizational challenges include regional coordination and specific protocols. Technological challenges mainly concern telecommunication networks.

Conclusions

Specific adaptations will be necessary if regional telestroke networks are to include remote robotics. Some of these can already be put in place, which could greatly help the future implementation of the technology.

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-assisted percutaneous coronary intervention: experience in Switzerland

Aims of the study

Percutaneous coronary intervention (PCI) exposes operators to ionizing radiation. Robotic-assisted PCI (RA-PCI) is a novel technology that enables interventional cardiologists to operate coronary devices remotely from a radiation-shed cockpit. The aim of this study is to describe the experience and challenges during the initiation of a RA-PCI program and to report outcomes of the first 21 patients undergoing RA-PCI in Switzerland.

Methods

All patients undergoing RA-PCI using the CorPath GRX Vascular Robotic System between 06/2021 and 12/2021 at Inselspital, Bern University Hospital were included in this retrospective registry study. Baseline, procedural and clinical follow-up data were prospectively assessed as part of the Cardiobase Bern PCI registry (NCT02241291). The two endpoints of interest were clinical success [defined as <30% residual diameter stenosis in the absence of in-hospital major adverse cardiovascular events (MACE: composite of death, periprocedural myocardial infarction, target-vessel revascularization, and stroke)] and robotic success (defined as clinical success and completion of RA-PCI without or with partial manual assistance). Additional outcome measures include clinical long-term outcomes at one year.

Results

Twenty-five lesions in 21 patients were treated with RA-PCI (age 62.4 ± 9.1 years, 24% female). Clinical success was achieved in 100%, and robotic success in 81% (17/21 procedures, including 4 procedures requiring partial manual assistance). Manual conversion (e.g. manual completion of the procedure) occurred in 19% (4 procedures). Reasons for manual assistance or conversion were poor guiding-catheter back-up or platform limitations (4), adverse events (2x transient slow-flow that was solved manually), safety decision (1x vasovagal reaction not related to robotic approach), and software error (1). No in-hospital MACE occurred. During 12 months of follow-up, one patient suffered a non-target-vessel myocardial infarction requiring repeat PCI.

Conclusions

RA-PCI can safely be performed without clinically relevant robot-associated complications in selected patients with approximately 80% of procedures conducted without or with partial manual assistance.

Integrative Approaches in Acute Ischemic Stroke: From Symptom Recognition to Future Innovations

Among the high prevalence of cerebrovascular diseases nowadays, acute ischemic stroke stands out, representing a significant worldwide health issue with important socio-economic implications. Prompt diagnosis and intervention are important milestones for the management of this multifaceted pathology, making understanding the various stroke-onset symptoms crucial. A key role in acute ischemic stroke management is emphasizing the essential role of a multi-disciplinary team, therefore, increasing the efficiency of recognition and treatment. Neuroimaging and neuroradiology have evolved dramatically over the years, with multiple approaches that provide a higher understanding of the morphological aspects as well as timely recognition of cerebral artery occlusions for effective therapy planning. Regarding the treatment matter, the pharmacological approach, particularly fibrinolytic therapy, has its merits and challenges. Endovascular thrombectomy, a game-changer in stroke management, has witnessed significant advances, with technologies like stent retrievers and aspiration catheters playing pivotal roles. For select patients, combining pharmacological and endovascular strategies offers evidence-backed benefits. The aim of our comprehensive study on acute ischemic stroke is to efficiently compare the current therapies, recognize novel possibilities from the literature, and describe the state of the art in the interdisciplinary approach to acute ischemic stroke. As we aspire for holistic patient management, the emphasis is not just on medical intervention but also on physical therapy, mental health, and community engagement. The future holds promising innovations, with artificial intelligence poised to reshape stroke diagnostics and treatments. Bridging the gap between groundbreaking research and clinical practice remains a challenge, urging continuous collaboration and research.

Robot-Assisted Transarterial Chemoembolization of Hepatocellular Carcinoma Using a Coaxial Microcatheter Driving Controller-Responder Robot System: Clinical Pilot Study

PURPOSE

To evaluate the feasibility and safety of robot-assisted transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) using a new coaxial microcatheter driving controller-responder robot (CRR) system.

MATERIALS AND METHODS

A single-center prospective pilot study approved by the institutional review board was conducted using this CRR developed after analyzing 20 cases of conventional TACE procedures from May to October 2021. The study included 10 patients with HCCs: 5 (median age, 72 years; range, 64-73 years) underwent robot-assisted TACE, and 5 (median age, 57 years; range, 44-76 years) underwent conventional TACE for comparison. The feasibility and safety of robot-assisted TACE were evaluated by assessing the technical success, procedure time, adverse event rate, radiation dose, and early tumor response.

RESULTS

The entire TACE procedure was divided into 30 steps, of which 8 could be robotized. In robot-assisted TACE, technical success was achieved in 4 (80%) of 5 patients. No procedure-related adverse event was observed. The median procedure time was 56 minutes. At the 1-month follow-up, 3 of the 4 patients showed a complete or partial response after robot-assisted TACE. The median radiation doses for the operator and patients were 0.4 and 2,167.5 μSv in robot-assisted TACE and 53.2 and 2,989.7 μSv in conventional TACE, respectively.

CONCLUSIONS

Robot-assisted TACE using a new CRR system was feasible and safe for the treatment of HCC and could remarkably decrease radiation exposure for the operators.

Feasibility of robotic neuroendovascular surgery

BACKGROUND

Several recent reports of CorPath GRX vascular robot (Cordinus Vascular Robotics, Natick, MA) use intracranially suggest feasibility of neuroendovascular application. Further use and development is likely. During this progression it is important to understand endovascular robot feasibility principles established in cardiac and peripheral vascular literature which enabled extension intracranially. Identification and discussion of robotic proof of concept principals from sister disciplines may help guide safe and accountable neuroendovascular application.

OBJECTIVE

Summarize endovascular robotic feasibility principals established in cardiac and peripheral vascular literature relevant to neuroendovascular application.

METHODS

Searches of PubMed, Scopus and Google Scholar were conducted under PRISMA guidelines1 using MeSH search terms. Abstracts were uploaded to Covidence citation review (Covidence, Melbourne, AUS) using RIS format. Pertinent articles underwent full text review and findings are presented in narrative and tabular format.

RESULTS

Search terms generated 1642 articles; 177, 265 and 1200 results for PubMed, Scopus and Google Scholar respectively. With duplicates removed, title review identified 176 abstracts. 55 articles were included, 45 from primary review and 10 identified during literature review. As it pertained to endovascular robotic feasibility proof of concept 12 cardiac, 3 peripheral vascular and 5 neuroendovascular studies were identified.

CONCLUSIONS

Cardiac and peripheral vascular literature established endovascular robot feasibility and efficacy with equivalent to superior outcomes after short learning curves while reducing radiation exposure >95% for the primary operator. Limitations of cost, lack of haptic integration and coaxial system control continue, but as it stands neuroendovascular robotic implementation is worth continued investigation.

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.

Robotic Percutaneous Coronary Intervention (R-PCI): Time to Focus on the Pros and Cons

AIM

To assess the safety, efficiency, and device compatibility of the Second Generation Robotic System.

METHODS

Data on Robot-Assisted PCI (R-PCI) is frequently insufficient in India. Many articles were published in national, non-indexed journals that are not available online and are difficult to obtain. Recognizing these constraints, the current review is intended to compile the available data on this important new innovation technique. This review could encourage future research and serve as a valuable source of information.

RESULTS

/Conclusion: In terms of procedure efficiency, operator radiation reduction, and safety, the recent implementation and development of second-generation robotic systems have had a significant impact on interventional cardiology. This technology will play a significant role in the future of interventional cardiology as advancements eliminate the need for manual assistance, improve devices compatibility, and expand the use of robotics for telestenting procedures. A larger study demonstrating the safety and feasibility of tele-stenting over greater geographic distances, as well as addressing fundamental technical difficulties, would be required before attempting R-PCI.

Robotically-assisted neuro-endovascular procedures: Single-Center Experience and a Review of the Literature

INTRODUCTION

Robotics could expand treatment of rapidly progressive pathologies such as acute ischemic stroke, with the potential to provide populations in need prompt access to neuro-endovascular procedures.

METHODS

Robotically-assisted (RA) neuro-endovascular procedures (RANPs) performed at our institution were retrospectively examined (RA-group, RG). A control group of manual neuro-endovascular procedures was selected (manual group, MG). Total operating room (OR) time, procedural time, contrast media use, fluoroscopy time, conversion from RA to manual control, procedural success, and complication rates were compared. A learning curve was identified.

RESULTS

Forty-one (41) RANPs were analyzed. Ages ranged from 20-82 y.o. Indications included diagnostic cerebral angiography (37), extracranial carotid artery stenting (3), and transverse sinus stent (1). Total OR time was longer in RG (median 86 vs. 71 min, p < 0.01). Procedural time (median 56 vs. 45 min, p = 0.12), fluoroscopy time (median 12 vs. 12 min, p = 0.69) and contrast media usage (82 vs. 92 ml, p = 0.54) were not significantly different. Patient radiation exposure was similar, considering similar fluoroscopy times. Radiation exposure and lead apron use were virtually absent for the main surgeon in RG. Procedural success was 83% and conversion from RA to manual control was 17% in RG. No treatment-related complications occurred. A learning curve showed that, after the fifth procedure, procedural times reduced and stabilized.

CONCLUSIONS

This series may contribute to further demonstrating the safety and feasibility of RANPs. RANPs can potentially reduce radiation exposure and physical burden for health personnel, expand acute cerebrovascular treatment to underserved areas, and enhance telementoring. Prospective studies are necessary for results to be generalized.

The implications of 5G technology on cardiothoracic surgical services in India

The fifth-generation (5G) technology is finally making its long-anticipated arrival in India, where it has evoked much hope to advance healthcare accessibility and delivery to the masses as well as improving patient safety and efficiency. The 5G technology standard for broadband and cellular networks comes with improved coverage capability; better throughput, speed, bandwidth, and signal strength; and low latency. Such salient-advanced features could be the knight in shining armor for the cardiothoracic surgical community in bridging gaps in perioperative care, outreach, education, research, and much more.

Design, development and evaluation of an ergonomically designed dual-use mechanism for robot-assisted cardiovascular intervention

PURPOSE

Robot-assisted cardiovascular intervention has been recently developed, which enables interventionists to avoid x-ray radiation and improve their comfort. However, there are still some challenges in the robotic design, such as the inability of the interventionist to freely perform natural clinical techniques and the limited motion travel of the interventional tool. To overcome these challenges, this paper proposes an ergonomically designed dual-use mechanism for cardiovascular intervention (DMCI).

METHODS

DMCI can work as an ergonomic interface or a compact slave robot with unlimited motion travel. Our kinematic analysis of DMCI includes motion decoupling and coupling. Motion decoupling decomposes the translation and rotation from the interventionist's natural clinical actions at the master side. Motion coupling can calculate the input pulses of motors according to the desired rotation and translation, thus composing the motion of the intervention tool at the slave side.

RESULTS

Our kinematic analysis of DMCI has been experimentally verified, where the overall mean rotational errors are all less than 1° and translational errors are all less than 1 mm. We also evaluated the performance of the DMCI-based master-slave system, where the overall rotational and translational errors are 0.821 ± 0.753° and 0.608 ± 0.512 mm. Moreover, operators were found to be generally more efficient when using the DMCI-based interface compared to the conventional joystick.

CONCLUSION

We have validated our kinematic analysis of DMCI. The master-slave teleoperation experiment demonstrated that operators can freely perform natural clinical techniques through the DMCI-based interface, and the slave robot can replicate the operators' manipulation at the master side well.

Another Paradigm Shift? The Impact of Robotics in Stroke Intervention

The Publisher regrets that this article is an accidental duplication of an article that has already been published, http://doi.org/10.1016/j.wneu.2023.02.014. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/policies/article-withdrawal.

Technical and Clinical Progress on Robot-Assisted Endovascular Interventions: A Review

Prior methods of patient care have changed in recent years due to the availability of minimally invasive surgical platforms for endovascular interventions. These platforms have demonstrated the ability to improve patients' vascular intervention outcomes, and global morbidities and mortalities from vascular disease are decreasing. Nonetheless, there are still concerns about the long-term effects of exposing interventionalists and patients to the operational hazards in the cath lab, and the perioperative risks that patients undergo. For these reasons, robot-assisted vascular interventions were developed to provide interventionalists with the ability to perform minimally invasive procedures with improved surgical workflow. We conducted a thorough literature search and presented a review of 130 studies published within the last 20 years that focused on robot-assisted endovascular interventions and are closely related to the current gains and obstacles of vascular interventional robots published up to 2022. We assessed both the research-based prototypes and commercial products, with an emphasis on their technical characteristics and application domains. Furthermore, we outlined how the robotic platforms enhanced both surgeons' and patients' perioperative experiences of robot-assisted vascular interventions. Finally, we summarized our findings and proposed three key milestones that could improve the development of the next-generation vascular interventional robots.

Periprocedural and 30-day outcomes of robotic-assisted percutaneous coronary intervention used in the intravascular imaging guidance

In recent years, there have been several reports on robotic-assisted percutaneous coronary intervention (R-PCI), but few studies have been conducted on R-PCI performed under intravascular imaging guidance. To elucidate the periprocedural and postoperative 30-day outcomes of intravascular imaging-guided R-PCI, we performed a retrospective observational study on all patients in 102 consecutive cases who underwent R-PCI under intravascular imaging guidance at a single center in Japan from June 12, 2019 to February 18, 2021. The primary end point was 30-day survival, and the secondary end point was the incidence of complications. Intravascular imaging-guided R-PCI was performed 110 times in total on 125 lesions. The medians of procedural time, fluoroscopy time, contrast volume, patient entrance skin dose, and radiation exposure to the main operator were 49 min, 16 min, 67 mL, 0.62 Gy, and 0 μSv, respectively. Furthermore, 60.0% of target lesion branches were American College of Cardiology Foundation/American Heart Association classification type B2 or type C. However, in all cases, lesion dilatation was successful, and the final Thrombolysis in Myocardial Infarction flow grade was 3. The combination of manual operation was required in 12.7% of all cases, but 30-day survival was confirmed in all cases. There were two problems at the puncture site. One small distal branch artery dissection occurred due to manual operation, but no cardiovascular events (myocardial infarction, stroke) occurred and no target lesion restenosis was observed within 30 days of R-PCI. Hence, R-PCI using intravascular imaging demonstrated highly satisfactory treatment outcomes, and no complication caused by robotic operation was observed.

A Deep-Learning-Based Guidewire Compliant Control Method for the Endovascular Surgery Robot

Endovascular surgery is a high-risk operation with limited vision and intractable guidewires. At present, endovascular surgery robot (ESR) systems based on force feedback liberates surgeons' operation skills, but it lacks the ability to combine force perception with vision. In this study, a deep learning-based guidewire-compliant control method (GCCM) is proposed, which guides the robot to avoid surgical risks and improve the efficiency of guidewire operation. First, a deep learning-based model called GCCM-net is built to identify whether the guidewire tip collides with the vascular wall in real time. The experimental results in a vascular phantom show that the best accuracy of GCCM-net is 94.86 ± 0.31%. Second, a real-time operational risk classification method named GCCM-strategy is proposed. When the surgical risks occur, the GCCM-strategy uses the result of GCCM-net as damping and decreases the robot's running speed through virtual resistance. Compared with force sensors, the robot with GCCM-strategy can alleviate the problem of force position asynchrony caused by the long and soft guidewires in real-time. Experiments run by five guidewire operators show that the GCCM-strategy can reduce the average operating force by 44.0% and shorten the average operating time by 24.6%; therefore the combination of vision and force based on deep learning plays a positive role in improving the operation efficiency in ESR.

Modeling optimal patient transport in a stroke network capable of remote telerobotic endovascular therapy

BACKGROUND

Telerobotic endovascular therapy (EVT) has the potential to decrease time to treatment and expand existing networks of care to more rural populations. It is currently unclear how its implementation would impact existing stroke networks.

METHODS

Conditional probability models were generated to predict the probability of excellent outcome for patients with suspected large vessel occlusion (LVO). A baseline stroke network was created for California using existing intravenous thrombolysis (IVT) centers and comprehensive stroke centers (CSCs) capable of IVT and EVT. Optimal transport decisions and catchment areas were generated for the baseline model and three hypothetical scenarios through conversion of IVT centers at various distances from a CSC into centers capable of telerobotic EVT [i.e., hospitals ≥15 and <50 miles from a CSC were converted (Scenario 1), ≥50 and <100 miles (Scenario 2), and ≥100 miles (Scenario 3)]. Procedural times and success rates were varied systematically.

RESULTS

Telerobotic EVT centers decreased median travel time for LVO patients in all three scenarios. The estimated number of robotically treated LVOs per year in Scenarios 1, 2, and 3 were 2,172, 740, and 212, respectively. Scenario 1 (15-50 miles) was the most sensitive to robotic time delay and success rate, but all three scenarios were more sensitive to decreases in procedural success rate compared to time delay.

CONCLUSIONS

Telerobotic EVT has the potential to improve care for stroke patients outside of major urban centers. Compared to procedural time delays in robotic EVT, a decrease in procedural success rate would not be well tolerated.

Discrete soft actor-critic with auto-encoder on vascular robotic system

Instrument delivery is critical part in vascular intervention surgery. Due to the soft-body structure of instruments, the relationship between manipulation commands and instrument motion is non-linear, making instrument delivery challenging and time-consuming. Reinforcement learning has the potential to learn manipulation skills and automate instrument delivery with enhanced success rates and reduced workload of physicians. However, due to the sample inefficiency when using high-dimensional images, existing reinforcement learning algorithms are limited on realistic vascular robotic systems. To alleviate this problem, this paper proposes discrete soft actor-critic with auto-encoder (DSAC-AE) that augments SAC-discrete with an auxiliary reconstruction task. The algorithm is applied with distributed sample collection and parameter update in a robot-assisted preclinical environment. Experimental results indicate that guidewire delivery can be automatically implemented after 50k sampling steps in less than 15 h, demonstrating the proposed algorithm has the great potential to learn manipulation skill for vascular robotic systems.

Trends in the Development of Digital Technologies in Medicine

The introduction of digital technologies has led to transformation of the healthcare domain and alterations in the nature of medical services. This article reviews Russian and non-Russian practices in the use of digital technologies to solve clinical medical tasks and scientific research in seeking new methods and means for the diagnosis and treatment of diseases and the management of healthcare organizations.

Robotics in neurointerventional surgery: a systematic review of the literature

BACKGROUND

Robotically performed neurointerventional surgery has the potential to reduce occupational hazards to staff, perform intervention with greater precision, and could be a viable solution for teleoperated neurointerventional procedures.

OBJECTIVE

To determine the indication, robotic systems used, efficacy, safety, and the degree of manual assistance required for robotically performed neurointervention.

METHODS

We conducted a systematic review of the literature up to, and including, articles published on April 12, 2021. Medline, PubMed, Embase, and Cochrane register databases were searched using medical subject heading terms to identify reports of robotically performed neurointervention, including diagnostic cerebral angiography and carotid artery intervention.

RESULTS

A total of 8 articles treating 81 patients were included. Only one case report used a robotic system for intracranial intervention, the remaining indications being cerebral angiography and carotid artery intervention. Only one study performed a comparison of robotic and manual procedures. Across all studies, the technical success rate was 96% and the clinical success rate was 100%. All cases required a degree of manual assistance. No studies had clearly defined patient selection criteria, reference standards, or index tests, preventing meaningful statistical analysis.

CONCLUSIONS

Given the clinical success, it is plausible that robotically performed neurointerventional procedures will eventually benefit patients and reduce occupational hazards for staff; however, there is no high-level efficacy and safety evidence to support this assertion. Limitations of current robotic systems and the challenges that must be overcome to realize the potential for remote teleoperated neurointervention require further investigation.

Robotically performed diagnostic coronary angiography

OBJECTIVE

This study was performed to investigate the efficacy and safety of robotic diagnostic coronary angiography.

BACKGROUND

Robotic percutaneous coronary intervention is associated with marked reductions in physician radiation exposure. Development of robotic diagnostic coronary angiography might similarly impact occupational safety.

METHODS

Stable patients referred for coronary angiography were prospectively enrolled. After obtaining vascular access, diagnostic catheters were manually advanced over a wire to the ascending aorta. All subsequent catheter movements were performed robotically. The primary endpoint was procedural success, defined as robotic completion of coronary angiography without conversion to a manual procedure and the absence of procedural major adverse cardiovascular events (MACE-cardiac death, cardiac arrest, or stroke) and major angiographic complications (coronary/aortic dissection or embolization). The primary hypothesis was that the observed rate of the primary endpoint, evaluated at the completion of coronary angiography, would meet a pre-specified performance goal of 74.5%.

RESULTS

Among 46 consecutive patients (age 67 ± 12 years; 69.6% male), diagnostic coronary angiography was completed robotically in all cases without the need for manual conversion and without any MACE or major angiographic complications. Thus, procedural success was 100%, which was significantly higher than the pre-specified performance goal (p < 0.001). Robotic coronary angiography was completed using 2 [2, 3] catheters per case with a median procedural time of 15 [11, 20] minutes.

CONCLUSIONS

Robotic diagnostic coronary angiography was performed with 100% procedural success and no observed complications. These results support the performance of future studies to further explore robotic coronary angiography.

Safety and Efficacy of Robotic-Assisted PCI

PURPOSE OF REVIEW

Robotics has been used in multiple areas of procedural medical intervention. Robotic percutaneous coronary intervention (PCI) has been available since 2004. Its adoption has been slow with initial application in simple cases.

RECENT FINDINGS

With increasing adoption, robotic PCI has been applied to a broader variety of coronary substrates with demonstration of safety and efficacy. Improvements in the robotic console with future generation devices should add to the utility of this platform. Robotic PCI advances the innovations in endovascular space into a different dimension, removing the dependence of the procedure on patient-operator ergonomics and likely operator skill.

Remote telesurgery in humans: a systematic review

BACKGROUND

Since the conception of robotic surgery, remote telesurgery has been a dream upon which incredible technological advances haven been built. Despite the considerable enthusiasm for, there have been few published studies of remote telesurgery on humans.

METHODS

We performed a systematic review of the English literature (PubMed, EMbase, Inspec & Compendex and Web of Science) to report studies of remote telesurgery in humans. Keywords included telesurgery, remote surgery, long-distance surgery, and telerobotics. Subjects had to be human (live patients or cadavers). The operating surgeon had to be remote from the patient, separated by more than one kilometer. The article had to explicitly report the use of a long-distance telerobotic technique. Articles that focused on telepresence or tele-mentoring were excluded.

RESULTS

The study included eight articles published from 2001 to 2020. One manuscript (1 subject) described remote surgery on a cadaver model, and the other seven were on live humans (72 subjects). Procedure types included percutaneous, endovascular, laparoscopic, and transoral. Communication methods varied, with the first report using a telephone line and the most recent studies using a 5G network. Six of the studies reported signal latency as a single value and it ranged from 28 ms to 280 ms.

CONCLUSIONS

Few studies have described remote telesurgery in humans, and there is considerable variability in robotic and communication methods. Future efforts should work to improve reporting of signal latency and follow careful research methodology.

Telerobotic neurovascular interventions with magnetic manipulation

Advances in robotic technology have been adopted in various subspecialties of both open and minimally invasive surgery, offering benefits such as enhanced surgical precision and accuracy with reduced fatigue of the surgeon. Despite the advantages, robotic applications to endovascular neurosurgery have remained largely unexplored because of technical challenges such as the miniaturization of robotic devices that can reach the complex and tortuous vasculature of the brain. Although some commercial systems enable robotic manipulation of conventional guidewires for coronary and peripheral vascular interventions, they remain unsuited for neurovascular applications because of the considerably smaller and more tortuous anatomy of cerebral arteries. Here, we present a teleoperated robotic neurointerventional platform based on magnetic manipulation. Our system consists of a magnetically controlled guidewire, a robot arm with an actuating magnet to steer the guidewire, a set of motorized linear drives to advance or retract the guidewire and a microcatheter, and a remote-control console to operate the system under real-time fluoroscopy. We demonstrate our system's capability to navigate narrow and winding pathways both in vitro with realistic neurovascular phantoms representing the human anatomy and in vivo in the porcine brachial artery with accentuated tortuosity for preclinical evaluation. We further demonstrate telerobotically assisted therapeutic procedures including coil embolization and clot retrieval thrombectomy for treating cerebral aneurysms and ischemic stroke, respectively. Our system could enable safer and quicker access to hard-to-reach lesions while minimizing the radiation exposure to physicians and open the possibility of remote procedural services to address challenges in current stroke systems of care.

Telerobotic Endovascular Interventions and Their Potential for Cerebrovascular Treatment

After the introduction of the first robotic-assisted surgical procedures, the technology soon reached the world of endovascular specialists, giving rise to several publications about robotic-assisted endovascular therapy. Compared with conventional procedures, robotic-assisted procedures can be more accurate and reduce radiation exposure. The latest commercially available endovascular robotic system is the CorPath GRX, which can be operated remotely. Robotic-assisted approaches have proved applicable in the fields of coronary and peripheral vascular intervention and neurointervention. Remote intervention has already proved feasible in the coronary and peripheral vascular systems and, according to expert opinion, could revolutionize acute stroke management as well. We review current knowledge about robotic-assisted therapies and remote interventions, and the future prospects and pitfalls.

Minimally Invasive Intracerebral Hemorrhage Evacuation: A review

Intracerebral hemorrhage is a leading cause of morbidity and mortality worldwide. To date, there is no specific treatment that clearly provides a benefit in functional outcome or mortality. Surgical treatment for hematoma evacuation has not yet shown clear benefit over medical management despite promising preclinical studies. Minimally invasive treatment options for hematoma evacuation are under investigation but remain in early-stage clinical trials. Robotics has the potential to improve treatment. In this paper, we review intracerebral hemorrhage pathology, currently available treatments, and potential robotic approaches to date. We also discuss the future role of robotics in stroke treatment.

Safety and effectiveness of introducing a robotic-assisted percutaneous coronary intervention program in a tertiary center: a prospective study

BACKGROUND

Robotic-assisted percutaneous coronary intervention (PCI) is a novel technology that permits remote operation of interventional devices. However, little is known about the safety and effectiveness of introducing a robotic PCI program in a hospital already experienced in traditional coronary angioplasty.

METHODS

Prospective single-arm survey to assess the safety and effectiveness of robotic-assisted PCI in comparison to pre-defined performance goals. The study cohort comprised all consecutive cases treated with robotic PCI since its introduction. The safety primary endpoint was a composite of (I) overall death or (II) non-fatal adverse events related to target vessel complications (stent thrombosis, myocardial infarction, vessel perforation or cardiac tamponade, or repeat invasive treatment) during the index hospitalization. The efficacy primary endpoint was robotic-assisted procedural success, a composite of (I) successful dilatation of the target lesion and (II) successful robotic assistance, defined as absent non-planned manual conversion.

RESULTS

A total of 83 patients and 112 lesions were prospectively enrolled. The rate of angiographic success was 99.1%. From these, 97 lesions (86.6%) were treated with only robotic PCI or with hybrid according to the pre-interventional plan. The rates of efficacy and safety primary endpoints were 85.7% and 2.4% respectively (P<0.01 for non-inferior to the pre-defined performance threshold).

CONCLUSIONS

Introduction of robotic-assisted PCI in a tertiary center was associated with safe and effective results, comparable to pre-defined goals of optimal performance.

Robotics for neuroendovascular intervention: Background and primer

The simultaneous growth of robotic-assisted surgery and telemedicine in recent years has only been accelerated by the recent coronavirus disease 2019 pandemic. Robotic assistance for neurovascular intervention has garnered significant interest due to opportunities for tele-stroke models of care for remote underserved areas. Lessons learned from medical robots in interventional cardiology and neurosurgery have contributed to incremental but vital advances in medical robotics despite important limitations. In this article, we discuss robot types and their clinical justification and ethics, as well as a general overview on available robots in thoracic/abdominal surgery, neurosurgery, and cardiac electrophysiology. We conclude with current clinical research in neuroendovascular intervention and a perspective on future directions.

Robotic Percutaneous Coronary Intervention: The Good, the Bad, and What is to Come

The introduction of robots into healthcare has brought a wealth of opportunity for technical advancements, ranging from cleaning robots to disinfect hospital rooms to the high-tech surgical robots used in the operating room. Robotic-assisted percutaneous coronary intervention (R-PCI) has been a more recent development in the field, and is particularly revolutionary in that it serves to benefit the interventional cardiologist as well as the patient. Published data on R-PCI have shown its feasibility, safety, and more recently, its potential benefits. This review examines the current role of the robot in the catheterization laboratory, the authors’ experience with the most current generation of the robot, and what is yet to come.

Robotic-assisted intracranial aneurysm treatment: 1 year follow-up imaging and clinical outcomes

BACKGROUND

The use of robotics in medicine may enable increased technical accuracy, reduced procedural time and radiation exposure, and remote completion of procedures. We have previously described the first-in-human, robotic-assisted cerebral aneurysm treatment using the CorPath GRX Robotic System. In this report we discuss our early experiences and outcomes using this robotic device for endovascular treatment of intracranial aneurysms using stent-assisted coil embolization and flow diversion.

METHODS

The patient and disease characteristics, procedural details, and follow-up imaging and clinical outcomes of consecutive patients undergoing robotically-assisted intracranial aneurysm embolization between November 2019 and February 2020 are presented.

RESULTS

Six patients underwent robotically-assisted embolization of intracranial aneurysms. Four of the patients were treated with a neck-bridging stent (with or without coiling) and two patients were treated with a flow-diverting stent. Two patients were treated in the subacute period of subarachnoid hemorrhage and four patients were treated electively. All of the procedures could be completed robotically and there was no need for unplanned manual intervention. The technical success rate of the procedures was 100%. There was no morbidity or mortality associated with the procedures. One year follow-up imaging showed that four aneurysms were completely obliterated (Raymond-Roy Occlusion Classification (RROC) class I) and the remaining two were occluded with a residual neck (RROC class II).

CONCLUSIONS

The Corpath GRX Robotic System demonstrated a precise control over the microcatheter, wire and stent during aneurysm treatment. Robotic neuro-procedures seem to be safe and effective and demonstrate stable occlusion results in the midterm follow-up.

Opportunities and Barriers to Rural Telerobotic Surgical Health Care in 2021: Report and Research Agenda from a Stakeholder Workshop

Background: There are well-recognized challenges to delivering specialty health care in rural settings. These challenges are particularly evident for specialized surgical health care due to the lack of trained operators in rural communities. Telerobotic surgery could have a significant impact on the rural-urban health care gap, but thus far, the promise of this method of health care delivery has gone unrealized. With the increasing adoption of telehealth over the past year, along with the maturation of telecommunication and robotic technologies over the past 2 decades, a reappraisal of the opportunities and barriers to widespread implementation of telerobotic surgery is warranted. Here we report the outcome of a rural telerobotic stakeholder workshop to explore modern-day issues critical to the advancement of telerobotic surgical health care. Materials and Methods: We assembled a multidisciplinary stakeholder panel to participate in a 2-day Rural Telerobotic Surgery Stakeholder Workshop. Participants had diverse expertise, including specialty surgeons, technology experts, and representatives of the broader telerobotic health care ecosystem, including economists, lawyers, regulatory consultants, public health advocates, rural hospital administrators, nurses, and payers. The research team reviewed transcripts from the workshop with themes identified and research questions generated based on stakeholder comments and feedback. Results: Stakeholder discussions fell into four general themes, including (1) operating room team interactions, (2) education and training, (3) network and security, and (4) economic issues. The research team then identified several research questions within each of these themes and provided specific research strategies to address these questions. Conclusions: There are still important unanswered questions regarding the implementation and adoption of rural telerobotic surgery. Based on stakeholder feedback, we have developed a research agenda along with suggested strategies to address outstanding research questions. The successful execution of these research opportunities will fill critical gaps in our understanding of how to advance the widespread adoption of rural telerobotic health care.

Prehospital Stroke Triage

PURPOSE OF THE REVIEW

This article reviews prehospital organization in the treatment of acute stroke. Rapid access to an endovascular therapy (EVT) capable center and prehospital assessment of large vessel occlusion (LVO) are 2 important challenges in acute stroke therapy. This article emphasizes the use of transfer protocols to assure the prompt access of patients with an LVO to a comprehensive stroke center where EVT can be offered. Available prehospital clinical tools and novel technologies to identify LVO are also discussed. Moreover, different routing paradigms like first attention at a local stroke center ("drip and ship"), direct transfer of the patient to an endovascular center ("mothership"), transfer of the neurointerventional team to a local primary center ("drip and drive"), mobile stroke units, and prehospital management communication tools all aimed to improve connection and coordination between care levels are reviewed.

RECENT FINDINGS

Local observational data and mathematical models suggest that implementing triage tools and bypass protocols may be an efficient solution. Ongoing randomized clinical trials comparing drip and ship vs mothership will elucidate which is the more effective routing protocol.

SUMMARY

Prehospital organization is critical in realizing maximum benefit from available therapies in acute stroke. The optimal transfer protocols directed to accelerate EVT are under study, and more accurate prehospital triage tools are needed. To improve care in the prehospital setting, efficient tools based on patient factors, local geography, and hospital capability are needed. These tools would optimally lead to individualized real-time decision-making.

The Future of Endovascular Therapy

PURPOSE OF THE REVIEW

This article summarizes a broad range of the most recent advances and future directions in stroke diagnostics, endovascular robotics, and neuromodulation.

RECENT FINDINGS

In the past 5 years, the field of interventional neurology has seen major technological advances for the diagnosis and treatment of cerebrovascular diseases. Several new technologies became available to aid in complex prehospital stroke triage, stroke diagnosis, and interpretation of radiologic findings. Robotics and neuromodulation promise to expand access to established treatments and broaden neuroendovascular indications.

SUMMARY

Mobile applications offer a solution to simplify prehospital diagnostic and transfer decisions. Several prehospital devices are also under development to improve the accuracy of detection of large vessel occlusion (LVO). Artificial intelligence is now routinely used in early diagnosis of LVO and for detecting salvageability of the affected brain parenchyma. Technological advances have also paved the way to incorporate endovascular robotics and neuromodulation into practice. This may expand the deliverability of established treatments and facilitate the development of cutting-edge treatments for other complex neurologic diseases.

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.

Feasibility of robot-assisted neuroendovascular procedures

OBJECTIVE

Geographic factors prevent equitable access to urgent advanced neuroendovascular treatments. Robotic technologies may enable remote endovascular procedures in the future. The authors performed a translational, benchtop-to-clinical study to evaluate the in vitro and clinical feasibility of the CorPath GRX Robotic System for robot-assisted endovascular neurointerventional procedures.

METHODS

A series of bench studies was conducted using patient-specific 3D-printed models to test the system's compatibility with standard neurointerventional devices, including microcatheters, microwires, coils, intrasaccular devices, and stents. Optimal baseline setups for various procedures were determined. The models were further used to rehearse clinical cases. Subsequent to these investigations, a prospective series of 6 patients was treated using robotic assistance for complex, wide-necked intracranial saccular aneurysms between November 2019 and February 2020. The technical success, incidence of periprocedural complications, and need for conversion to manual procedures were evaluated.

RESULTS

The ideal robotic setup for treatment of both anterior and posterior circulation aneurysms was determined to consist of an 80-cm guide catheter with a 115-cm-long intermediate catheter, a microcatheter between 150 and 170 cm in length, and a microwire with a minimum length of 300 cm. All coils, intrasaccular devices, and stents tested were compatible with the system and could be advanced or retracted safely and placed accurately. All 6 clinical procedures were technically successful, with all intracranial steps being performed robotically with no conversions to manual intervention or failures of the robotic system. There were no procedure-related complications or adverse clinical outcomes.

CONCLUSIONS

This study demonstrates the feasibility of robot-assisted neurointerventional procedures. The authors' results represent an important step toward enabling remote neuroendovascular care and geographic equalization of advanced endovascular treatments through so-called telestroke intervention.

Fifth Generation Cellular Networks and Neurosurgery: A Narrative Review

Connectivity is a driving force for productivity across a wide variety of sectors in the 21st century, with health care being no exception. Fifth generation cellular technology (5G) is frequently alluded to in the mainstream media but understanding of the technology and its potential impact is not widespread in clinical communities. It promises unprecedented improvement in speed, bandwidth, reliability, and latency, all of which have significant implications for the way we use wireless data. 5G can be subdivided into 3 parallel technological architectures: extended mobile broadband (eMBB), ultra-reliable low latency communication (URLLC), and massive machine type communication (mMTC). These domains each present different and exciting prospects for the future of health care. This narrative review aims to elucidate the nature of 5G, its context within the development of telecommunications, and describe some of the notable opportunities it presents to the neurosurgical community. In many cases the requisite hardware has already been developed, but use has been limited by the requirements of a fast, reliable, and omnipresent network connection. Examples include telesurgical robots, remote supervision of procedures, integrated smart operating rooms, and clinician telepresence. The events of 2020 and the COVID-19 pandemic have brought the world's attention to digital transformation. The mechanics of 5G connectivity creates the capacity for these changes to be applied practically. An understanding of this technology is essential to appreciate the development and opportunities which will be part of our professional future.

Robotics, imaging, and artificial intelligence in the catheterisation laboratory

The catheterisation laboratory today combines diagnosis and therapeutics, through various imaging modalities and a prolific list of interventional tools, led by balloons and stents. In this review, we focus primarily on advances in image-based coronary interventions. The X-ray images that are the primary modality for diagnosis and interventions are combined with novel tools for visualisation and display, including multi-imaging co-registration modalities with three- and four-dimensional presentations. Interpretation of the physiologic significance of coronary stenosis based on prior angiographic images is being explored and implemented. Major efforts to reduce X-ray exposure to the staff and the patients, using computer-based algorithms for image processing, and novel methods to limit the radiation spread are being explored. The use of artificial intelligence (AI) and machine learning for better patient care requires attention to universal methods for sharing and combining large data sets and for allowing interpretation and analysis of large cohorts of patients. Barriers to data sharing using integrated and universal protocols should be overcome to allow these methods to become widely applicable. Robotic catheterisation takes the physician away from the ionising radiation spot, enables coronary angioplasty and stenting without compromising safety, and may allow increased precision. Remote coronary procedures over the internet, that have been explored in virtual and animal studies and already applied to patients in a small pilot study, open possibilities for sharing experience across the world without travelling. Application of those technologies to neurovascular, and particularly stroke interventions, may be very timely in view of the need for expert neuro-interventionalists located mostly in central areas.

Robotic-assisted percutaneous coronary intervention in the COVID-19 pandemic

Coronavirus disease-2019 (COVID-19) has a profound impact on the health care system worldwide. In the COVID-19 pandemic, hospitals are required to halt elective surgeries and procedures for preventing nosocomial infections and saving medical resources. In these situations, emergency procedures are required for life-threatening cardiovascular diseases such as acute coronary syndrome and cardiogenic shock. To prevent the spread of COVID-19, a social distance is essentially required. In ordinary percutaneous coronary intervention (PCI), operators manipulate the devices standing at the patient's tableside during the whole procedure, which may involve a certain risk of exposure to patients with COVID-19. A robotic-assisted PCI (R-PCI) allows operators to manipulate devices remotely, sitting at a cockpit located several meters away from the patient, and in addition, the assistant can be at the foot of the bed, much further from the access site. R-PCI can help to minimize the radiation exposure and the amount of person-to-person contact, and consequently may reduce the risk for the exposure to the virus.

Remote robotic endovascular thrombectomy for acute ischaemic stroke

Background

In acute ischaemic stroke, endovascular thrombectomy (ET) significantly reduces disability compared with thrombolytic therapy, but access to ET is currently limited. Leveraging telerobotic technology to disseminate neurosurgical expertise could increase access to ET. This proof-of-concept evaluation was performed to determine whether remote robotic ET (RRET), wherein an offsite neurosurgeon and an onsite interventional cardiologist collaboratively use telerobotics to perform ET, is technically feasible.

Methods

An ex vivo model of RRET was constructed by establishing a network connection between a robotic drive in a simulation laboratory and a robotic control unit 5 miles away. Using onsite assistance from an interventional cardiologist in the simulation laboratory, an offsite neurosurgeon used the robotic controls to attempt RRET on a fluid-filled silicone model of human vasculature containing simulated thrombus material in the left middle cerebral artery (MCA).

Results

From the offsite location 5 miles away, the neurosurgeon used the robotic system to successfully navigate a guidewire from the carotid artery to simulated thrombus in the MCA. Under the direction of the neurosurgeon, the onsite interventional cardiologist then successfully manually advanced an aspiration catheter over the guidewire to the thrombus, removed the guidewire and performed aspiration.

Conclusions

In this proof-of-concept evaluation, the technical feasibility of RRET was demonstrated in an ex vivo model and was collaboratively performed by an offsite neurosurgeon and an onsite interventional cardiologist. This report supports the design of future studies to determine if RRET could be used to increase access to ET for patients with acute ischaemic stroke.