Robot-assisted Fenestrated Endovascular Aneurysm Repair (FEVAR) Using the Magellan System

The evolution of robotics: research and application progress of dental implant robotic systems

The use of robots to augment human capabilities and assist in work has long been an aspiration. Robotics has been developing since the 1960s when the first industrial robot was introduced. As technology has advanced, robotic-assisted surgery has shown numerous advantages, including more precision, efficiency, minimal invasiveness, and safety than is possible with conventional techniques, which are research hotspots and cutting-edge trends. This article reviewed the history of medical robot development and seminal research papers about current research progress. Taking the autonomous dental implant robotic system as an example, the advantages and prospects of medical robotic systems would be discussed which would provide a reference for future research.

Dexterous helical magnetic robot for improved endovascular access

Treating vascular diseases in the brain requires access to the affected region inside the body. This is usually accomplished through a minimally invasive technique that involves the use of long, thin devices, such as wires and tubes, that are manually maneuvered by a clinician within the bloodstream. By pushing, pulling, and twisting, these devices are navigated through the tortuous pathways of the blood vessels. The outcome of the procedure heavily relies on the clinician's skill and the device's ability to navigate to the affected target region in the bloodstream, which is often inhibited by tortuous blood vessels. Sharp turns require high flexibility, but this flexibility inhibits translation of proximal insertion to distal tip advancement. We present a highly dexterous, magnetically steered continuum robot that overcomes pushability limitations through rotation. A helical protrusion on the device's surface engages with the vessel wall and translates rotation to forward motion at every point of contact. An articulating magnetic tip allows for active steerability, enabling navigation from the aortic arch to millimeter-sized arteries of the brain. The effectiveness of the magnetic continuum robot has been demonstrated through successful navigation in models of the human vasculature and in blood vessels of a live pig.

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.

A novel endovascular robotic-assisted system for endovascular aortic repair: first-in-human evaluation of practicability and safety

OBJECTIVES

To assess the practicability and safety of a novel endovascular robotic system for performing endovascular aortic repair in human.

METHODS

A prospective observational study was conducted in 2021 with 6 months post-operative follow-up. Patients with aortic aneurysms and clinical indications for elective endovascular aortic repair were enrolled in the study. The novel developed robotic system is applicable for the majority of commercial devices and various types of endovascular surgeries. The primary endpoint was technical success without in-hospital major adverse events. Technical success was defined as the ability of the robotic system to complete all procedural steps based on procedural segments.

RESULTS

The first-in-human evaluation of robot-assisted endovascular aortic repair was performed in five patients. The primary endpoint was achieved in all patients (100%). There were no device- or procedure-related complications or no in-hospital major adverse events. The operation time and total blood loss in these cases were equal to those in the manual procedures. The radiation exposure of the surgeon was 96.5% lower than that in the traditional position while the radiation exposure of the patients was not significantly increased.

CONCLUSIONS

Early clinical evaluation of the novel endovascular aortic repair in endovascular aortic repair demonstrated practicability, safety, and procedural effectiveness comparable to manual operation. In addition, the total radiation exposure of the operator was significantly lower than that of traditional procedures.

CLINICAL RELEVANCE STATEMENT

This study applies a novel approach to perform the endovascular aortic repair in a more accurate and minimal-invasive way and lays the foundation for the perspective automation of the endovascular robotic system, which reflects a new paradigm for endovascular surgery.

KEY POINTS

• This study is a first-in-human evaluation of a novel endovascular robotic system for endovascular aortic repair (EVAR). • Our system might reduce the occupational risks associated with manual EVAR and contribute to achieving a higher degree of precision and control. • Early evaluation of the endovascular robotic system demonstrated practicability, safety, and procedural effectiveness comparable to that of manual operation.

First-in-human robotic percutaneous coronary intervention by the ROSES robotic system: a case report

Background

Robotic-assisted percutaneous coronary intervention (R-PCI) is increasingly gaining acceptance owing to several advantages.

Case summary

Here, we report the first-in-human R-PCI performed with RObotic System for Endovascular Surgery (ROSES), an innovative robotic system designed to perform transcatheter angioplasty. We have reported a case of severe proximal posterolateral (PL) branch disease of the right coronary artery managed with R-PCI.

Discussion

In this early clinical experience, the use of the ROSES robotic system seems to be safe and effective. However, this report still represents an early feasibility study, and the use of this technology in more challenging anatomies including the presence of severe tortuosity, severe calcification, or interventions requiring multiple wires and balloons needs to be further studied. A larger, prospective, multicentre pivotal clinical trial designed to test the ROSES robotic angioplasty system in a larger number of patients is currently ongoing.

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.

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.

Current State of Robotics in Interventional Radiology

As a relatively new specialty with a minimally invasive nature, the field of interventional radiology is rapidly growing. Although the application of robotic systems in this field shows great promise, such as with increased precision, accuracy, and safety, as well as reduced radiation dose and potential for teleoperated procedures, the progression of these technologies has been slow. This is partly due to the complex equipment with complicated setup procedures, the disruption to theatre flow, the high costs, as well as some device limitations, such as lack of haptic feedback. To further assess these robotic technologies, more evidence of their performance and cost-effectiveness is needed before their widespread adoption within the field. In this review, we summarise the current progress of robotic systems that have been investigated for use in vascular and non-vascular interventions.

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.

Kinetics Analysis and ADRC-Based Controller for a String-Driven Vascular Intervention Surgical Robotic System

Vascular interventional surgery is a typical method for diagnosing and treating cardio-cerebrovascular diseases. However, a surgeon is exposed to significant X-radiation exposure when the operation is conducted for a long period of time. A vascular intervention surgical robotic system for assisting the surgeon is a promising approach to address the aforementioned issue. When developing the robotic system, a high displacement accuracy is crucial, and this can aid in enhancing operating efficiency and safety. In this study, a novel kinetics analysis and active disturbance rejection control (ADRC)-based controller is proposed to provide high accuracy for a string-driven robotic system. In this controller, kinetics analysis is initially used to improve the accuracy affected by the inner factors of the slave manipulator. Then, the ADRC controller is used to further improve the operating accuracy of the robotic system. Finally, the proposed controller is evaluated by conducting experiments on a vascular model. The results indicate maximum steady errors of 0.45 mm and 6.67°. The experimental results demonstrate that the proposed controller can satisfy the safety requirements of the string-driven robotic system.

A Novel Remote-Controlled Vascular Interventional Robotic System Based on Hollow Ultrasonic Motor

Cardiovascular diseases (CVDs) are the deadliest diseases worldwide. Master-slave robotic systems have been widely used in vascular interventional surgery with the benefit of high safety, efficient operation, and procedural facilitation. This paper introduces a remote-controlled vascular interventional robot (RVIR) that aims to enable surgeons to perform complex vascular interventions reliably and accurately under a magnetic resonance imaging (MRI) environment. The slave robot includes a guidewire manipulator (GM) and catheter manipulator (CM) that are mainly composed of a hollow driving mechanism and a linear motion platform. The hollow driving mechanism is based on a traveling wave-type hollow ultrasonic motor (HUM) which has high positional precision, fast response, and magnetic interference resistance and realizes the cooperation of the guidewire and catheter by omitting the redundant transmission mechanism and maintaining good coaxiality. The HUM stator, the core part of the RVIR, is optimized by an adaptive genetic algorithm for better quality and greater amplitude of traveling waves, which are beneficial to the drive efficiency and precision. The robot system features great cooperating performance, small hysteresis, and high kinematic accuracy and has been experimentally verified for its capability to precisely manipulate the guidewire and catheter.

Robot-assisted techniques in vascular and endovascular surgery

For thousands of years, robots have inspired the imagination of humans, but it was only about 35 years ago that a robot was used for the first time in medicine. Since then, robot-assisted procedures have become increasingly popular in urology, general surgical specialties, and gynecology. Robot-assisted vascular surgery was first introduced in 2002 and was thought to overcome the limitations of laparoscopy. However, it did not gain widespread popularity, and its usage is still limited to a few centers worldwide. Robot-assisted endovascular procedures, on the other hand, while still in its infancy, have become a promising alternative to existing techniques. The improvements of the robotic systems promote better surgical performance and reduce occupational hazards for vascular and endovascular surgeons. A comprehensive review of literature was performed using the search terms “robotic,” “robot assisted,” “vascular surgery,” and “aortic” for surgical procedures or “robotic,” “robot assisted,” and “endovascular” for endovascular procedures. Full text articles that were published between January 1990 and March 2021 were included. This review summarizes the development of the techniques for robot-assisted vascular and endovascular surgery in recent years, its outcomes, advantages, disadvantages, and perspectives.

Magnetically Driven Soft Continuum Microrobot for Intravascular Operations in Microscale

Remotely controlled soft continuum robots with active steering capability have broad prospects in medical applications. However, conventional continuum robots have the miniaturization challenge. This paper presents a microscale soft continuum microrobot with steering and locomotion capabilities based on magnetic field actuation. The magnetically driven soft continuum microrobot is made of NdFeB particles and polydimethylsiloxane (PDMS), and it can be as small as 200 μm in diameter. Moreover, a hydrogel layer is covered on the surface of the microrobot, which not only overcomes the adhesion force between the microobjects and the soft tip but also reduces the friction between the microrobot and substrate. The performance test indicates the soft continuum microrobot featured excellent control and steering capabilities. The experimental results demonstrate that the soft continuum microrobot can travel through the microfluidic channel by its own vibration and flexibly steer in a bifurcation environment. Moreover, the micromanipulation of microbeads in the microfluidic channels proves that the proposed microscale soft continuum microrobot has a great potential for intravascular manipulation.

Systematic Review of Telemedicine and eHealth Systems Applied to Vascular Surgery

OBJECTIVE

The objective of this paper is to review and analyze the current state of telemedicine and ehealth in the field of vascular surgery.

METHODS

This paper collects the relevant information obtained after reviewing the articles related to telemedicine in vascular surgery, published from 2012 to 2022 contained in scientific databases. In addition, the results obtained are statistically studied based on various factors, such as the year of publication or the search engine. In this way, we obtain a complete vision of the current state of telemedicine in the field of vascular surgery.

RESULTS

After performing this search and applying selection criteria, 29 articles were obtained for subsequent study and discussion, of which 20 were published in the second half of the decade, representing 70% of the results. In the analysis carried out according to the search criteria used, it can be seen that using the word telemedicine we obtained 69% of the articles while with the criteria mHealth and eHealth we only obtained 22% and 9% of the results, respectively. It can be seen that the filter with the most potential content articles was "vascular surgery AND telemedicine". In the analysis performed according to the search engine, it was observed that the Google Scholar database contains 93% of the articles found in the massive search and the relevant articles contained therein represent 52% of the total.

CONCLUSION

An upward trend has been observed in recent years, with a clear increase in the number of publications and much lower figures in the first years. One aspect to highlight is that 47.8% of the articles analyzed focus only on postoperative treatment, which may be due to the help provided by telemedicine in detecting surgical site infections by sending images and videos, this being one of the most common postoperative complications. The analyzed works show the importance of telemedicine in vascular surgery and identify possible future lines of research. In the analysis carried out on the origin of the selected relevant papers, an important interest of the US in this topic is demonstrated since more than 50% of the research contains authors from this country, it is also observed that there is no research from Spain, so this research would be an initial step to determine the weaknesses of telemedicine in this field of medicine and a good opportunity to open a research gap in this branch.

Robotic endovascular surgery: current and future practice

Minimally invasive techniques have been at the forefront of surgical progress, and the evolution of endovascular robotic technologies has seen a paradigm shift in the focus of future innovation. Endovascular robotic technology may help overcome many of the challenges associated with traditional endovascular techniques by enabling greater control, stability, and precision of target navigation and treatment, while simultaneously reducing operator learning curves and improving safety. Several robotic systems have been developed to perform a broad range of endovascular procedures, but none have been used at scale or widely in routine practice, and the evidence for their safety, effectiveness, and efficiency remains limited. High cost and device complexity, lack of haptic feedback, and limited integration and interoperability with existing equipment and devices are the principal technology, cost, and sustainability barriers to the scalability and widespread adoption in day-to-day practice. In order to fully realize its potential, future robotic innovation must ensure compatibility with a range of off-the-shelf equipment that can be tracked and exchanged quickly during a procedure and come together with developments in navigation, tracking, and imaging. Reducing cost and complexity and supporting sustainability of the technology is key. In parallel, new technologies must be evaluated by clear and transparent standardized outcomes and be accompanied by robust clinical training. Key to the successful future development and dissemination of robotic technology is open collaboration among industry, clinicians, and patients in order to fully understand and address current challenges and enable the technology to realize its full potential.

ADRC-Based Control Method for the Vascular Intervention Master-Slave Surgical Robotic System

In vascular interventional surgery, surgeons operate guidewires and catheters to diagnose and treat patients with the assistance of the digital subtraction angiography (DSA). Therefore, the surgeon will be exposed to X-rays for extended periods. To protect the surgeon, the development of a robot-assisted surgical system is of great significance. The displacement tracking accuracy is the most important issue to be considered in the development of the system. In this study, the active disturbance rejection control (ADRC) method is applied to guarantee displacement tracking accuracy. First, the core contents of the proportional–integral–derivative (PID) and ADRC methods are analyzed. Second, comparative evaluation experiments for incremental PID and ADRC methods are presented. The results show that the ADRC method has better performance of than that of the incremental PID method. Finally, the calibration experiments for the ADRC control method are implemented using the master–slave robotic system. These experiments demonstrate that the maximum tracking error is 0.87 mm using the ADRC method, effectively guaranteeing surgical safety.

Precision Interventional Brachytherapy: A Promising Strategy Toward Treatment of Malignant Tumors

Precision interventional brachytherapy is a radiotherapy technique that combines radiation therapy medicine with computer network technology, physics, etc. It can solve the limitations of conventional brachytherapy. Radioactive drugs and their carriers change with each passing day, and major research institutions and enterprises worldwide have conducted extensive research on them. In addition, the capabilities of interventional robotic systems are also rapidly developing to meet clinical needs for the precise delivery of radiopharmaceuticals in interventional radiotherapy. This study reviews the main radiopharmaceuticals, drug carriers, dispensing and fixation technologies, and interventional robotic precision delivery systems used in precision brachytherapy of malignant tumors. We then discuss the current needs in the field and future development prospects in high-precision interventional brachytherapy.

A Vascular Intervention Assist Device Using Bi-Motional Roller Cartridge Structure and Clinical Evaluation

Conventional vascular intervention procedures present issues including X-ray exposure during operation, and an experience-dependent success rate and clinical outcome. This paper presents a novel robotic system using modularized bi-motional roller cartridge assemblies for robotic vascular interventions, specifically percutaneous coronary interventions (PCIs). The patient-side robot manipulates instruments such as the guiding catheter, guidewire, balloon/stent catheter, and diagnostic sensor catheter via commands from the user interface device, which is controlled by the physician. The proposed roller cartridge assembly can accommodate instruments of various sizes with an active clamping mechanism, and implements simultaneous translation and rotation motions. It also implements force feedback in the physician-side system, to effectively monitor the patient-side system’s status. The positioning accuracy and precision in using the robotic system showed satisfactory performance in a phantom-based test. It was also confirmed, through animal experiments and a pilot clinical trial, that the system demonstrates feasibility for clinical use.

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.

Comparison of manual versus robot-assisted contralateral gate cannulation in patients undergoing endovascular aneurysm repair

PURPOSE

Robotic endovascular technology may offer advantages over conventional manual catheter techniques. Our aim was to compare the endovascular catheter path-length (PL) for robotic versus manual contralateral gate cannulation during endovascular aneurysm repair (EVAR), using video motion analysis (VMA).

METHODS

This was a multicentre retrospective cohort study with fluoroscopic video recordings of 24 EVAR cases (14 robotic, 10 manual) performed by experienced operators (> 50 procedures), obtained from four leading European centres. Groups were comparable with no statistically significant differences in aneurysm size (p = 0.47) or vessel tortuosity (p = 0.68). Two trained assessors used VMA to calculate the catheter PL during contralateral gate cannulation for robotic versus manual approaches.

RESULTS

There was a high degree of inter-observer reliability (Cronbach's α > 0.99) for VMA. Median robotic PL was 35.7 cm [interquartile range, IQR (30.8-51.0)] versus 74.1 cm [IQR (44.3-170.4)] for manual cannulation, p = 0.019. Robotic cases had a median cannulation time of 5.33 min [IQR (4.58-6.49)] versus 1.24 min [IQR (1.13-1.35)] in manual cases (p = 0.0083). Generated efficiency ratios (PL/aorto-iliac centrelines) was 1.6 (1.2-2.1) in robotic cases versus 2.6 (1.7-7.0) in manual, p = 0.031.

CONCLUSION

Robot-assisted contralateral gate cannulation in EVAR leads to decreased navigation path lengths and increased economy of movement compared with manual catheter techniques. The benefit could be maximised by prioritising robotic catheter shaping over habituated reliance on guidewire manipulation. Robotic technology has the potential to reduce the endovascular footprint during manipulations even for experienced operators with the added advantage of zero radiation exposure.

A Remote-Controlled Robotic System with Safety Protection Strategy Based on Force-Sensing and Bending Feedback for Transcatheter Arterial Chemoembolization

Transcatheter arterial chemoembolization (TACE) is the common choice of non-open surgery for hepatocellular carcinoma (HCC) now. In this study, a simple TACE robotic system of 4-degree-of-freedom is proposed to get higher accuracy and stability of the surgery operation and reduce X-ray exposure time of the surgeons. The master-slave control strategy is adopted in the robotic system and a customized sigmoid function is designed to optimize the joystick control of the master-slave robotic control system. A force-sensing module is developed to sense the resistance of the guide wire in linear delivery motion and an auxiliary bending feedback method based on constraint pipe with a film sensor is proposed. With two force-sensing methods, the safety strategy of robotic motion with 9 different motion constraint coefficients is given and a human-computer interface is developed. The TACE robot would monitor the value of the force sensor and the analog voltage of the film sensor to adopt the corresponding motion constraint coefficient in every 10 ms. Vascular model experiments were performed to validate the robotic system, and the results showed that the safety strategy could improve the reliability of the operation with immediate speed constraint and avoid potential aggressive delivery.

A novel SEA-based haptic force feedback master hand controller for robotic endovascular intervention system

Robotic Endovascular Intervention System (REIS) has been a focused and interesting area in robot-assisted telesurgery. While, haptic feedback is the latest advancing study in interventional robots. Few systems with haptic feedback are commercialized due to accuracy, instantaneity, and the lack of surgeon previous experience on interventional surgery. In this article, a novel haptic force feedback master hand controller system is proposed to solve the problems. A SEA (Series Elastic Actuators)-based mechanism is designed to provide feedback force with high force/torque fidelity, low impedance, and inertia. Also, the handle of the mechanism is similar to the catheter, making the surgeon operate the telesurgery with his experience. The control model of the system is built, and PID algorithms are explored to realize the motion control. PID parameters are optimized for fast response time and stability. The experiments and results demonstrate that the master hand controller system has maximum feedback force relative error of 3%, instantaneity of 0.89 second and tracking performance of 9 Hz frequency 3 dB bandwidth.

A vascular interventional surgical robot based on surgeon's operating skills

Interventional surgery is widely used in the treatment of cardiovascular and cerebrovascular diseases, and the development of surgical robots can greatly reduce the fatigue and radiation risks brought to surgeons during surgery. In this paper, we present a novel interventional surgical robot which allows surgeons to fully use their operating skills during remote control. Fuzzy control theory is used to guarantee control precision during the master-slave operation. The safety force feedback control is designed based on the catheter and guidewire spring model, and the force-position control is designed to decrease the potential damage due to the control delay. This study first evaluates the force-position control strategy using a vascular model experiment, and then an in vivo experiment is used to evaluate the precision of the surgical robot controlling the catheter and guidewire to the designated position. The in vivo experiment results and surgeon's feedback demonstrate that the proposed surgical robot is able to perform complex remote surgery in clinical application. Graphical abstract Surgeons perform remote interventional animal surgery using interventional surgical robots.

Frontiers of Medical Robotics: From Concept to Systems to Clinical Translation

Medical robotics is poised to transform all aspects of medicine—from surgical intervention to targeted therapy, rehabilitation, and hospital automation. A key area is the development of robots for minimally invasive interventions. This review provides a detailed analysis of the evolution of interventional robots and discusses how the integration of imaging, sensing, and robotics can influence the patient care pathway toward precision intervention and patient-specific treatment. It outlines how closer coupling of perception, decision, and action can lead to enhanced dexterity, greater precision, and reduced invasiveness. It provides a critical analysis of some of the key interventional robot platforms developed over the years and their relative merit and intrinsic limitations. The review also presents a future outlook for robotic interventions and emerging trends in making them easier to use, lightweight, ergonomic, and intelligent, and thus smarter, safer, and more accessible for clinical use.

[Evolution of transcatheter aortic valve implantation: from planning to robotic systems]

Since its introduction in 2002, transcatheter aortic valve implantation (TAVI) has evolved dramatically and is now standard of care for intermediate risk patients with aortic stenosis. The development of innovative transcatheter heart valves and refinement of technical skills have contributed to the decrease in complication rates associated with TAVI. Increased experience, smaller sheaths, rigorous pre-procedural planning and improved vascular closing techniques have resulted in markedly lower rates of vascular complications. The next step was the simplification of the procedure, which contributed to a further decrease in complications, reduced procedural time, and shorter hospital stay. Change-over from general anaesthesia to conscious sedation, refusal from predilatation, and use of the radial approach instead of the contralateral femoral approach are all instrumental in achieving optimal results. Prospects for development include visual assist systems and robotic systems that can potentially optimize the transcatheter aortic valve implantation process, improve safety and effectiveness of the procedure.

Analysis of Interventionalists' Natural Behaviors for Recognizing Motion Patterns of Endovascular Tools During Percutaneous Coronary Interventions

Many robotic platforms can indeed reduce radiation exposure to clinicians during percutaneous coronary intervention (PCI), however, interventionalists' natural manipulations are rarely involved in robot-assisted PCI. This requires more attention to analyze interventionalists' natural behaviors during conventional PCI. In this study, four types of natural behavior (i.e., muscle activity, hand motion, proximal force, and finger motion) were synchronously acquired from ten subjects while performing six typical types of guidewire manipulation. These behaviors are evaluated by a hidden Markov model (HMM) based analysis framework for relevant behavior selection. Relevant behaviors are further used as the input of two HMM-based classification frameworks to recognize guidewire motion patterns. Experimental results show that under the basic classification framework (BCF), 91.01% and 93.32% recognition accuracies can be achieved by using all behaviors and relevant behaviors, respectively. Furthermore, the hierarchical classification framework can significantly enhance the recognition ability of relevant behaviors with an accuracy of 96.39%. These promising results demonstrate great potential of proposed methods for promoting the future design of human-robot interfaces in robot-assisted PCI.

Steering Algorithm for a Flexible Microrobot to Enhance Guidewire Control in a Coronary Angioplasty Application

Magnetically driven microrobots have been widely studied for various biomedical applications in the past decade. An important application of these biomedical microrobots is heart disease treatment. In intravascular treatments, a particular challenge is the submillimeter-sized guidewire steering; this requires a new microrobotic approach. In this study, a flexible microrobot was fabricated by the replica molding method, which consists of three parts: (1) a flexible polydimethylsiloxane (PDMS) body, (2) two permanent magnets, and (3) a micro-spring connector. A mathematical model was developed to describe the relationship between the magnetic field and the deformation. A system identification approach and an algorithm were proposed for steering. The microrobot was fabricated, and the models for steering were experimentally validated under a magnetic field intensity of 15 mT. Limitations to control were identified, and the microrobot was steered in an arbitrary path using the proposed model. Furthermore, the flexible microrobot was steered using the guidewire within a three-dimensional (3D) transparent phantom of the right coronary artery filled with water, to show the potential application in a realistic environment. The flexible microrobot presented here showed promising results for enhancing guidewire steering in percutaneous coronary intervention (PCI).

Endovascular robotics

The current state and the future direction.

A marker-based contactless catheter-sensing method to detect surgeons' operations for catheterization training systems

It is challenging to position a catheter or a guidewire within a patient's complicated and delicate vascular structure due to the lack of intuitive visual feedback by only manipulating the proximal part of the surgical instruments. Training is therefore critical before an actual surgery because any mistake due to the surgeon's inexperience can be fatal for the patient. The catheter manipulation skills of experienced surgeons can be useful as input for training novice surgeons. However, few research groups focused on designs with consideration of the contactless catheter motion measurement, which allows obtaining expert surgeons' catheter manipulation trajectories whilst still allowing them to employ an actual catheter and apply conventional pull, push and twist of the catheter as used in bedside intravascular interventional surgeries. In this paper, a novel contactless catheter-sensing method is proposed to measure the catheter motions by detecting and tracking a passive marker with four feature-point groups. The passive marker is designed to allow simultaneously sensing the translational and rotational motions of the input catheter. Finally, the effectiveness of the proposed contactless catheter-sensing method is validated by conducting a series of comparison experiments. The accuracy and error analysis are quantified based on the absolute error, relative error, mean absolute error, and the success rate of the detection.

Compensatory force measurement and multimodal force feedback for remote-controlled vascular interventional robot

Minimally invasive vascular interventional surgery is widely used and remote-controlled vascular interventional surgery robots (RVIRs) are being developed to reduce the occupational risk of the intervening physician in minimally invasive vascular interventional surgeries. Skilled surgeon performs surgeries mainly depending on the detection of collisions. Inaccurate force feedback will be difficult for surgeons to perform surgeries or even results in medical accidents. In addition, the surgeon cannot quickly and easily distinguish whether the proximal force exceeds the safety threshold of blood vessels or not, and thus it results in damage to the blood vessels. In this paper, we present a novel method comprising compensatory force measurement and multimodal force feedback (MFF). Calibration experiments and performance evaluation experiments were carried out. Experimental results demonstrated that the proposed method can measure the proximal force of catheter/guidewire accurately and assist surgeons to distinguish the change of proximal force more easily. This novel method is suitable for use in actual surgical operations.

Towards Characterization and Adaptive Compensation of Backlash in a Novel Robotic Catheter System for Cardiovascular Interventions

Despite the success and prospects of the robotic catheter system for the cardiovascular access, loss of vision, and haptics have limited its global adoption. A direct implication is the great difficulty posed when trying to eliminate the backlash in catheters during vascular cannulations. As a result, physicians and patients end up been exposed to high radiation for a long period of time. Existing control systems proposed for such interventional robots have not fully consider the hysteretic (backlash) behavior. In this study, a novel robotic catheter system is designed for accessing the human cardiac area through the radial vasculature, while single factor descriptive analysis is employed to characterize the backlash behavior during axial motions of the interventional robot. Based on the descriptive analysis, an adaptive system is proposed for the backlash compensation during the cardiovascular access. The adaptive system consists of a neuro-fuzzy module that predicts a backlash gap based on bounded motion signals, and contact force modulated from a modified error-based force control model. The proposed system is implemented in MATLAB and visual C++. Finally, an in vitro experiment with a human tubular model, shows that the proposed adaptive compensation system can minimize the backlash occurrence during cardiovascular access.

Learning-based endovascular navigation through the use of non-rigid registration for collaborative robotic catheterization

PURPOSE

Endovascular intervention is limited by two-dimensional intraoperative imaging and prolonged procedure times in the presence of complex anatomies. Robotic catheter technology could offer benefits such as reduced radiation exposure to the clinician and improved intravascular navigation. Incorporating three-dimensional preoperative imaging into a semiautonomous robotic catheterization platform has the potential for safer and more precise navigation. This paper discusses a semiautonomous robotic catheter platform based on previous work (Rafii-Tari et al., in: MICCAI2013, pp 369-377. https://doi.org/10.1007/978-3-642-40763-5_46 , 2013) by proposing a method to address anatomical variability among aortic arches. It incorporates anatomical information in the process of catheter trajectories optimization, hence can adapt to the scale and orientation differences among patient-specific anatomies.

METHODS

Statistical modeling is implemented to encode the catheter motions of both proximal and distal sites based on cannulation data obtained from a single phantom by an expert operator. Non-rigid registration is applied to obtain a warping function to map catheter tip trajectories into other anatomically similar but shape/scale/orientation different models. The remapped trajectories were used to generate robot trajectories to conduct a collaborative cannulation task under flow simulations. Cross-validations were performed to test the performance of the non-rigid registration. Success rates of the cannulation task executed by the robotic platform were measured. The quality of the catheterization was also assessed using performance metrics for manual and robotic approaches. Furthermore, the contact forces between the instruments and the phantoms were measured and compared for both approaches.

RESULTS

The success rate for semiautomatic cannulation is 98.1% under dry simulation and 94.4% under continuous flow simulation. The proposed robotic approach achieved smoother catheter paths than manual approach. The mean contact forces have been reduced by 33.3% with the robotic approach, and 70.6% less STDEV forces were observed with the robot.

CONCLUSIONS

This work provides insights into catheter task planning and an improved design of hands-on ergonomic catheter navigation robots.

Operation evaluation in-human of a novel remote-controlled vascular interventional robot

Remote-controlled vascular interventional robots (RVIRs) are being developed to increase the accuracy of surgical operations and reduce the number of occupational risks sustained by intervening physicians, such as radiation exposure and chronic neck/back pain. However, complex control of the RVIRs improves the doctor's operation difficulty and reduces the operation efficiency. Furthermore, incomplete sterilization of the RVIRs will increase the risk of infection, or even cause medical accidents. In this study, we introduced a novel method that provides higher operation efficiency than a previous prototype and allows for complete robot sterilization. A prototype was fabricated and validated through laboratory setting experiments and an in-human experiment. The results illustrated that the proposed RVIR has better performance compared with the previous prototype, and preliminarily demonstrated that the proposed RVIR has good safety and reliability and can be used in clinical surgeries.

A cooperation of catheters and guidewires-based novel remote-controlled vascular interventional robot

Remote-controlled vascular interventional robots (RVIRs) are being developed to increase the overall accuracy of surgical operations and reduce the occupational risks of intervening physicians, such as radiation exposure and chronic neck/back pain. Several RVIRs have been used to operate catheters or guidewires accurately. However, a lack of cooperation between the catheters and guidewires results in the surgeon being unable to complete complex surgery by propelling the catheter/guidewire to the target position. Furthermore, it is a significant challenge to operate the catheter/guidewire accurately and detect their proximal force without damaging their surfaces. In this study, we introduce a novel method that allows catheters and guidewires to be operated simultaneously in complex surgery. Our method accurately captures force measurements and enables precisely controlled catheter and guidewire operation. A prototype is validated through various experiments. The results demonstrate the feasibility of the proposed RVIR to operate a catheter and guidewire accurately, detect the resistance forces, and complete complex surgical operations in a cooperative manner.

An HMM-based recognition framework for endovascular manipulations

Robotic surgical systems are becoming increasingly popular for the treatment of cardiovascular diseases. However, most of them have been designed without considering techniques and skills of natural surgical manipulations, which are key factors to clinical success of percutaneous coronary intervention. This paper proposes an HMM-based framework to recognize six typical endovascular manipulations for surgical skill analysis. A simulative surgical platform is built for endovascular manipulations assessed by five subjects (1 expert and 4 novices). The performances of the proposed framework are evaluated by three experimental schemes with the optimal model parameters. The results show that endovascular manipulations are recognized with high accuracy and reliable performance. Furthermore, the acceptable results can also be applied to the design of next generation vascular interventional robots.

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.

Current applications and future perspectives of robotics in cerebrovascular and endovascular neurosurgery

Advances in robotic medicine have been adopted by various surgical subspecialties as the benefits of this technology become more readily apparent: precision in narrow operative windows, tremor controlled movements, and modestly improved outcomes, among others. Vascular neurosurgery, in particular, remains open to newer and more cutting edge treatment options for complex pathologies, and robotics may be on the horizon for such advances. We seek to provide a broad overview of these innovations in vascular neurosurgery for both practitioners well acquainted with robotics and those seeking to become more familiar. Technologies under development for cerebrovascular and endovascular neurosurgery include robot assisted angiography, guided operative microscopes, coil insertion systems, and endoscopic clipping devices. Additionally, robotic systems in the fields of interventional cardiology and radiology have potential applications to endovascular neurosurgery but require proper modifications to navigate complex intracerebral vasculature. Robotic technology is not without drawbacks, as broad implementation may lead to increased cost, training time, and potential delays in emergency situations. Further cultivation of current multidisciplinary technologies and investment into newer systems is necessary before robotics can make a sizable impact in clinical practice.

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.

Application of emerging technologies to improve access to ischemic stroke care

During the past 20 years, the traditional supportive treatment for stroke has been radically transformed by advances in catheter technologies and a cohort of prominent randomized controlled trials that unequivocally demonstrated significant improvement in stroke outcomes with timely endovascular intervention. However, substantial limitations to treatment remain, among the most important being timely access to care. Nonetheless, stroke care has continued its evolution by incorporating technological advances from various fields that can further reduce patients' morbidity and mortality. In this paper the authors discuss the importance of emerging technologies—mobile stroke treatment units, telemedicine, and robotically assisted angiography—as future tools for expanding access to the diagnosis and treatment of acute ischemic stroke.

Transbrachial branch cannulation during Zenith fenestrated endovascular aortic aneurysm repair using a robotically guided body-floss technique

Caudal angulation and stenosis of the renal arteries pose significant challenges in branch cannulation during the standard fenestrated endovascular aortic aneurysm repair (FEVAR). We describe an alternative technique of branch cannulation during FEVAR in a patient with a 6.5-cm juxtarenal abdominal aortic aneurysm, renal artery stenosis, and bilateral caudally oriented renal arteries. A brachiofemoral or "body-floss" access was established by traversing the top scallop. The brachial sheath was deflected toward the target fenestration using a steerable robotic femoral sheath, enabling transbrachial cannulation of the downgoing target renal artery. Postoperatively, the patient was discharged without complications. Steerable sheath-guided body-floss technique may facilitate cannulation of severely downgoing branch vessels during FEVAR.

Motion-adapted catheter navigation with real-time instantiation and improved visualisation

The improvements to catheter manipulation by the use of robot-assisted catheter navigation for endovascular procedures include increased precision, stability of motion and operator comfort. However, navigation through the vasculature under fluoroscopic guidance is still challenging, mostly due to physiological motion and when tortuous vessels are involved. In this paper, we propose a motion-adaptive catheter navigation scheme based on shape modelling to compensate for these dynamic effects, permitting predictive and dynamic navigations. This allows for timed manipulations synchronised with the vascular motion. The technical contribution of the paper includes the following two aspects. Firstly, a dynamic shape modelling and real-time instantiation scheme based on sparse data obtained intra-operatively is proposed for improved visualisation of the 3D vasculature during endovascular intervention. Secondly, a reconstructed frontal view from the catheter tip using the derived dynamic model is used as an interventional aid to user guidance. To demonstrate the practical value of the proposed framework, a simulated aortic branch cannulation procedure is used with detailed user validation to demonstrate the improvement in navigation quality and efficiency.