Augmented reality navigation to assist retrograde peroneal access for the endovascular treatment of critical limb ischemia

Retrograde Peroneal Artery Approach to Treat Infra-Inguinal Arterial Chronic Total Occlusions: A Multicentre Experience and Technical Considerations

Background/Objectives: Retrograde access of the peroneal artery (PA) is considered technically challenging and at risk of bleeding. The aim of this multicentre retrospective study was to assess the safety, feasibility, and technical success of this access route for infrainguinal endovascular recanalizations. Methods: We retrospectively analyzed 186 consecutive patients treated over a 7-year period (May 2014-August 2021) who underwent endovascular recanalization of infra-inguinal lesions using a PA access route. In all cases, retrograde PA access was obtained following a failed attempt to cross the occlusion via the antegrade route. Results: Among the 186 patients, 120 were males (60.5%) and the mean age was 76.8 ± 10.7 years old (44-94 years). One hundred and thirteen patients (60.7%) suffered from chronic limb threatening ischemia (CLTI). All patients presented with chronic total occlusions (CTO) and a failed conventional antegrade recanalization attempt. Retrograde access was performed under angiographic guidance in 185 cases (99.5%). It was successfully established in 171 cases (91.9%). The total rate of retrograde puncture-related complications was 2.1% (two puncture site bleedings of which one necessitated fasciotomy and two cases of arteriovenous fistulas managed conservatively). The Major Adverse Event (MAE) rate at 30 days was 1.6% (3/186). Conclusions: Retrograde recanalization of challenging infra-inguinal lesions via PA is safe and effective in experienced hands.

A New Method for Common Femoral Arterial Access Using a Mixed Reality-Assisted Technique on a Phantom Model

PURPOSE

The purpose of this study was to investigate the technical feasibility and usability of a mixed reality (MiR)-assisted common femoral arterial (CFA) access technique using a sonography-assisted registration method.

MATERIALS AND METHODS

A total of 60 CFA punctures were performed on a phantom model by 2 observers. Thirty punctures were performed using MiR (MiR group) and 30 punctures were performed using a conventional sonography-guided access procedure (control group). In the MiR group, a virtual object was created based on a computed tomography (CT) angiography scan of the model and registered to the physical patient in an MiR environment utilizing a software prototype that allowed registration based on a sonography scan. Positional error assessment encompassed 4 measurements using cone beam CT scans: (1) distance of the needle tip to the centerline, (2) distance of the needle entry site from the mid-level of the ostium of the profound femoral artery, (3) angle of entry of the needle in coronal, and (4) sagittal planes. Technical success rates as well as positional errors were compared between both groups. In addition, the usability of the system was assessed according to the system usability scale (SUS).

RESULTS

Technical success was 96.7% and 100% in the MiR and control groups, respectively. The median distance between the needle tip and the centerline was 3.0 (interquartile range [IQR]: 2.0-4.6) in the MiR group and 3.2 mm (IQR: 2.3-3.9) (p=0.63) in the control group. Similarly, the median distance from the needle entry site to the mid-level of the ostium of the profound femoral artery was 3.0 mm (IQR: 2.0-5.0) in the MiR group and 4.5 mm (IQR: 2.0-7.8) (p=0.18) in the control group. The median coronal angles of needle entry were 7.5° (IQR: 6-11) and 6° (IQR: 2-12) (p=0.13), and the median sagittal angles were 50° (IQR: 47-51) and 51° (IQR: 50-55) (p<0.01) in the MiR and control groups, respectively. The mean SUS score provided by both observers was 51.3.

CONCLUSION

The feasibility of an MiR-assisted CFA access technique could be demonstrated on a phantom model. Further studies are needed to investigate the technique beyond phantom model experiments and in different anatomical settings.

CLINICAL IMPACT

This study demonstrates the technical feasibility of a Mixed-Reality-assisted common femoral arterial access procedure on a phantom model. The positional accuracy was comparable to a conventional sonography-guided technique. However, there are several limitations that need to be resolved prior to potential implementation into clinical practice. Further studies are needed to investigate its performance beyond phantom model experiments and the prototypical application requires further technical refinement to increase its usability.

Artificial Intelligence, Computational Simulations, and Extended Reality in Cardiovascular Interventions

Artificial intelligence, computational simulations, and extended reality, among other 21st century computational technologies, are changing the health care system. To collectively highlight the most recent advances and benefits of artificial intelligence, computational simulations, and extended reality in cardiovascular therapies, we coined the abbreviation AISER. The review particularly focuses on the following applications of AISER: 1) preprocedural planning and clinical decision making; 2) virtual clinical trials, and cardiovascular device research, development, and regulatory approval; and 3) education and training of interventional health care professionals and medical technology innovators. We also discuss the obstacles and constraints associated with the application of AISER technologies, as well as the proposed solutions. Interventional health care professionals, computer scientists, biomedical engineers, experts in bioinformatics and visualization, the device industry, ethics committees, and regulatory agencies are expected to streamline the use of AISER technologies in cardiovascular interventions and medicine in general.

Mixed Reality in der Gefäßchirurgie – ein Scoping Review

Hintergrund „Mixed Reality“ (MR) erlaubt die Projektion von virtuellen Objekten in das Sichtfeld des Anwenders durch ein Head-mounted Display (HMD). Im gefäßchirurgischen Behandlungsspektrum könnten MR-Anwendungen in Zukunft einen Nutzen darstellen. Im folgenden Scoping Review soll eine Orientierung über die aktuelle Anwendung der genannten Technologien im Bereich der Gefäßchirurgie gegeben und Forschungsziele für die Zukunft definiert werden. Material und Methoden Es erfolgte eine systematische Literaturrecherche in PubMed (MEDLINE) mit den Suchbegriffen „aorta“, „intervention“, „endovsacular intervention“, „vascular surgery“, „aneurysm“, „endovascular“, „vascular access“ jeweils in Kombination mit „mixed reality“ oder „augmented reality“. Die Suche erfolgte nach PRISMA-Leitlinie (Preferred Reporting Items for Systematic reviews and Meta-Analyses) für Scoping Reviews. Ergebnisse Aus 547 Literaturstellen konnten 8 relevante Studien identifiziert werden. Die Suchergebnisse konnten in 2 Anwendungskategorien eingeteilt werden: (1) MR mit dem Ziel des Informationsmanagements und zur Verbesserung der periprozeduralen Ergonomie gefäßchirurgischer Eingriffe (n = 3) sowie (2) MR mit dem Ziel der intraoperativen Navigation bei gefäßchirurgischen Eingriffen (n = 5). Die Registrierung des physischen Patienten mit dem virtuellen Objekt und das Tracking von Instrumenten in der MR-Umgebung zur intraoperativen Navigation ist dabei im Fokus des wissenschaftlichen Interesses und konnte technisch erfolgreich am Phantom- und Tiermodell gezeigt werden. Die bisher vorgestellten Methoden sind jedoch mit hohem infrastrukturellem Aufwand und relevanten Limitationen verbunden. Schlussfolgerung Der Einsatz von MR im Bereich der Gefäßchirurgie ist grundsätzlich vielversprechend. Für die Zukunft sollten alternative, pragmatische Registrierungsmethoden mit entsprechender Quantifizierung des Positionierungsfehlers angestrebt werden. Die entwickelten Soft- und Hardwarelösungen sollten auf das Anforderungsprofil der Gefäßchirurgie angepasst werden. Das elektromagnetische Instrumenten-Tracking erscheint als sinnvolle, komplementäre Technologie zur Umsetzung der MR-assistierten Navigation.

Augmented Reality in Vascular and Endovascular Surgery: Scoping Review

Background

Technological advances have transformed vascular intervention in recent decades. In particular, improvements in imaging and data processing have allowed for the development of increasingly complex endovascular and hybrid interventions. Augmented reality (AR) is a subject of growing interest in surgery, with the potential to improve clinicians’ understanding of 3D anatomy and aid in the processing of real-time information. This study hopes to elucidate the potential impact of AR technology in the rapidly evolving fields of vascular and endovascular surgery.

Objective

The aim of this review is to summarize the fundamental concepts of AR technologies and conduct a scoping review of the impact of AR and mixed reality in vascular and endovascular surgery.

Methods

A systematic search of MEDLINE, Scopus, and Embase was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. All studies written in English from inception until January 8, 2021, were included in the search. Combinations of the following keywords were used in the systematic search string: (“augmented reality” OR “hololens” OR “image overlay” OR “daqri” OR “magic leap” OR “immersive reality” OR “extended reality” OR “mixed reality” OR “head mounted display”) AND (“vascular surgery” OR “endovascular”). Studies were selected through a blinded process between 2 investigators (JE and AS) and assessed using data quality tools.

Results

AR technologies have had a number of applications in vascular and endovascular surgery. Most studies (22/32, 69%) used 3D imaging of computed tomography angiogram–derived images of vascular anatomy to augment clinicians’ anatomical understanding during procedures. A wide range of AR technologies were used, with heads up fusion imaging and AR head-mounted displays being the most commonly applied clinically. AR applications included guiding open, robotic, and endovascular surgery while minimizing dissection, improving procedural times, and reducing radiation and contrast exposure.

Conclusions

AR has shown promising developments in the field of vascular and endovascular surgery, with potential benefits to surgeons and patients alike. These include reductions in patient risk and operating times as well as in contrast and radiation exposure for radiological interventions. Further technological advances are required to overcome current limitations, including processing capacity and vascular deformation by instrumentation.

Bioengineering, augmented reality, and robotic surgery in vascular surgery: A literature review

Biomedical engineering integrates a variety of applied sciences with life sciences to improve human health and reduce the invasiveness of surgical procedures. Technological advances, achieved through biomedical engineering, have contributed to significant improvements in the field of vascular and endovascular surgery. This paper aims to review the most cutting-edge technologies of the last decade involving the use of augmented reality devices and robotic systems in vascular surgery, highlighting benefits and limitations. Accordingly, two distinct literature surveys were conducted through the PubMed database: the first review provides a comprehensive assessment of augmented reality technologies, including the different techniques available for the visualization of virtual content (11 papers revised); the second review collects studies with bioengineering content that highlight the research trend in robotic vascular surgery, excluding works focused only on the clinical use of commercially available robotic systems (15 papers revised). Technological flow is constant and further advances in imaging techniques and hardware components will inevitably bring new tools for a clinical translation of innovative therapeutic strategies in vascular surgery.

Augmented reality, virtual reality and new age technologies demand escalates amid COVID-19

The coronavirus disease (COVID-19) pandemic is having a significant impact on healthcare, education, economics and general human well-being. Augmented reality (AR) and virtual reality (VR) have experienced a tremendous increase in demand as they play an important role in avoiding travel, social contacts and providing adequate audiovisual communication and virtual presence. AR/VR is helping in the fight of this pandemic through their deployment in various crucial areas such as telemedicine, online education and training, marketing and healthcare monitoring. AR/VR provides resolutions for the distribution of antibiotics to control the spread of the COVID-19 virus. This paper discusses the demand for AR and VR as well as other notable new technologies explored recently to support the fight against COVID-19. The same technologies are in high demand, in the form of 2D-3D visualization and tracking software, flow and dynamic wearable headsets, potentially responsible for displaying the geographic location mostly affected with COVID-19.