Advantage of Steerable Catheter and Haptic Feedback for a 5-DOF Vascular Intervention Robot System

A haptic guidance system for simulated catheter navigation with different kinaesthetic feedback profiles

BACKGROUND

This paper proposes a haptic guidance system to improve catheter navigation within a simulated environment.

METHODS

Three force profiles were constructed to evaluate the system: collision prevention; centreline navigation; and a novel force profile of reinforcement learning (RL). All force profiles were evaluated from the left common iliac to the right atrium.

RESULTS

Our findings show that providing haptic feedback improved surgical safety compared to visual-only feedback. If staying inside the vasculature is the priority, RL provides the safest option. It is also shown that the performance of each force profile varies in different anatomical regions.

CONCLUSION

The implications of these findings are significant, as they hold the potential to improve how and when haptic feedback is applied for cardiovascular intervention.

Path tracking control of a steerable catheter in transcatheter cardiology interventions

PURPOSE

Intracardiac transcatheter interventions allow for reducing trauma and hospitalization stays as compared to standard surgery. In the treatment of mitral regurgitation, the most widely adopted transcatheter approach consists in deploying a clip on the mitral valve leaflets by means of a catheter that is run through veins from a peripheral access to the left atrium. However, precise manipulation of the catheter from outside the body while copying with the path constraints imposed by the vessels remains challenging.

METHODS

We proposed a path tracking control framework that provides adequate motion commands to the robotic steerable catheter for autonomous navigation through vascular lumens. The proposed work implements a catheter kinematic model featuring nonholonomic constraints. Relying on the real-time measurements from an electromagnetic sensor and a fiber Bragg grating sensor, a two-level feedback controller was designed to control the catheter.

RESULTS

The proposed method was tested in a patient-specific vessel phantom. A median position error between the center line of the vessel and the catheter tip trajectory was found to be below 2 mm, with a maximum error below 3 mm. Statistical testing confirmed that the performance of the proposed method exhibited no significant difference in both free space and the contact region.

CONCLUSION

The preliminary in vitro studies presented in this paper showed promising accuracy in navigating the catheter within the vessel. The proposed approach enables autonomous control of a steerable catheter for transcatheter cardiology interventions without the request of calibrating the intuitive parameters or acquiring a training dataset.

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.

Toward Autonomous Pulmonary Artery Catheterization: A Learning-based Robotic Navigation System

Providing imaging during interventional treatments of cardiovascular diseases is challenging. Magnetic Resonance Imaging (MRI) has gained popularity as it is radiation-free and returns high resolution of soft tissue. However, the clinician has limited access to the patient, e.g., to their femoral artery, within the MRI scanner to accurately guide and manipulate an MR-compatible catheter. At the same time, communication will need to be maintained with a clinician, located in a separate control room, to provide the most appropriate image to the screen inside the MRI room. Hence, there is scope to explore the feasibility of how autonomous catheterization robots could support the steering of catheters along trajectories inside complex vessel anatomies.In this paper, we present a Learning from Demonstration based Gaussian Mixture Model for a robot trajectory optimisation during pulmonary artery catheterization. The optimisation algorithm is integrated into a 2 Degree-of-Freedom MR-compatible interventional robot allowing for continuous and simultaneous translation and rotation. Our methodology achieves autonomous navigation of the catheter tip from the inferior vena cava, through the right atrium and the right ventricle into the pulmonary artery where an interventions is performed. Our results show that our MR-compatible robot can follow an advancement trajectory generated by our Learning from Demonstration algorithm. Looking at the overall duration of the intervention, it can be concluded that procedures performed by the robot (teleoperated or autonomously) required significantly less time compared to manual hand-held procedures.

A Novel Master-Slave Interventional Surgery Robot with Force Feedback and Collaborative Operation

In recent years, master-slave vascular robots have been developed to address the problem of radiation exposure during vascular interventions for surgeons. However, the single visual feedback reduces surgeon immersion and transparency of the system. In this work, we have developed a haptic interface based on the magnetorheological fluid (MRF) on the master side. The haptic interface can provide passive feedback force with high force fidelity and low inertia. Additionally, the manipulation of the master device does not change the operating posture of traditional surgery, which allows the surgeon to better adapt to the robotic system. For the slave robot, the catheter and guidewire can be navigated simultaneously which allows the two degrees of action on the catheter and axial action of a guidewire. The resistance force of the catheter navigation is measured and reflected to the user through the master haptic interface. To verify the proposed master-slave robotic system, the evaluation experiments are carried out in vitro, and the effectiveness of the system was demonstrated experimentally.

Experimental Protocol and Phantom Design and Development for Performance Characterization of Conventional Devices for Peripheral Vascular Interventions

Conventional catheter-based interventions for treating peripheral artery disease suffer high failure and complication rates. The mechanical interactions with the anatomy constrain catheter controllability, while their length and flexibility limit their pushability. Also, the 2D X-ray fluoroscopy guiding these procedures fails to provide sufficient feedback about the device location relative to the anatomy. Our study aims to quantify the performance of conventional non-steerable (NS) and steerable (S) catheters in phantom and ex vivo experiments. In a 10 mm diameter, 30 cm long artery phantom model, with four operators, we evaluated the success rate and crossing time in accessing 1.25 mm target channels, the accessible workspace, and the force delivered through each catheter. For clinical relevance, we evaluated the success rate and crossing time in crossing ex vivo chronic total occlusions. For the S and NS catheters, respectively, users successfully accessed 69 and 31% of the targets, 68 and 45% of the cross-sectional area, and could deliver 14.2 and 10.2 g of mean force. Using a NS catheter, users crossed 0.0 and 9.5% of the fixed and fresh lesions, respectively. Overall, we quantified the limitations of conventional catheters (navigation, reachable workspace, and pushability) for peripheral interventions; this can serve as a basis for comparison with other devices.

Design and evaluation of vascular interventional robot system for complex coronary artery lesions

At present, most vascular intervention robots cannot cope with the more common coronary complex lesions in the clinic. Moreover, the lack of effective force feedback increases the risk of surgery. In this paper, a vascular interventional robot that can collaboratively deliver multiple interventional instruments has been developed to assist doctors in the operation of complex lesions. Based on the doctor's skills and the delivery principle of interventional instruments, the main and slave manipulators of the robot system are designed. Haptic force feedback is generated through resistance measuring mechanism and active drag system. In addition, a force feedback control strategy based on force-velocity mapping is proposed to realize the continuous change of force and avoid vibration. The proposed robot system was evaluated through a series of experiments. The experimental results show that the system can accurately measure the delivery resistance of interventional instruments, and provide haptic force feedback to doctors. The capability of the system to collaboratively deliver multiple interventional instruments is effective. Therefore, it can be considered that the robot system is feasible and effective.

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.

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.

An Electromagnetically Controllable Microrobotic Interventional System for Targeted, Real-Time Cardiovascular Intervention

Robotic magnetic manipulation systems offer a wide range of potential benefits in medical fields, such as precise and selective manipulation of magnetically responsive instruments in difficult-to-reach vessels and tissues. However, more preclinical/clinical studies are necessary before robotic magnetic interventional systems can be widely adopted. In this study, a clinically translatable, electromagnetically controllable microrobotic interventional system (ECMIS) that assists a physician in remotely manipulating and controlling microdiameter guidewires in real time, is reported. The ECMIS comprises a microrobotic guidewire capable of active magnetic steering under low-strength magnetic fields, a human-scale electromagnetic actuation (EMA) system, a biplane X-ray imaging system, and a remote guidewire/catheter advancer unit. The proposed ECMIS demonstrates targeted real-time cardiovascular interventions in vascular phantoms through precise and rapid control of the microrobotic guidewire under EMA. Further, the potential clinical effectiveness of the ECMIS for real-time cardiovascular interventions is investigated through preclinical studies in coronary, iliac, and renal arteries of swine models in vivo, where the magnetic steering of the microrobotic guidewire and control of other ECMIS modules are teleoperated by operators in a separate control booth with X-ray shielding. The proposed ECMIS can help medical physicians optimally manipulate interventional devices such as guidewires under minimal radiation exposure.

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.

Remote vascular interventional surgery robotics: a literature review

Vascular interventional doctors are exposed to radiation hazards during surgery and endure high work intensity. Remote vascular interventional surgery robotics is a hot research field, in which researchers aim to not only protect the health of interventional doctors, but to also improve surgical accuracy and efficiency. However, the current vascular interventional robots have numerous shortcomings, such as poor haptic feedback, few compatible surgeries and instruments, and cumbersome maintenance and operational procedures. Nevertheless, vascular interventional surgery combined with robotics provides more cutting-edge directions, such as Internet remote surgery combined with 5G network technology and the application of artificial intelligence in surgical procedures. To summarize the developmental status and key technical points of intravascular interventional surgical robotics research, we performed a systematic literature search to retrieve original articles related to remote vascular interventional surgery robotics published up to December 2020. This review, which includes 113 articles published in English, introduces the mechanical and structural characteristics of various aspects of vascular interventional surgical robotics, discusses the current key features of vascular interventional surgical robotics in force sensing, haptic feedback, and control methods, and summarizes current frontiers in autonomous surgery, long-distance robotic telesurgery, and magnetic resonance imaging (MRI)-compatible structures. On the basis of summarizing the current research status of remote vascular interventional surgery robotics, we aim to propose a variety of prospects for future robotic systems.

Cardiac X-ray image-based haptic guidance for robot-assisted coronary intervention: a feasibility study

PURPOSE

Effective and efficient haptic guidance is desirable for tele-operated robotic surgery because it has a potential to enhance surgeon's skills, especially in coronary interventions where surgeon loses both an eye-hand coordination and a direct sight to the organ. This paper proposes a novel haptic guidance procedure-both kinesthetic and cutaneous, which solely depends upon X-ray images, for tele-robotic system that assists an efficient navigation of the guidewire towards the target location during a coronary intervention.

METHODS

Proposed methodology requires cardiologists to draw virtual fixtures (VFs) on angiograms as a preoperative procedure. During an operation, these VFs direct the guidewire to the desired coronary vessel. For this, the position and orientation of guidewire tip are calculated with respect to VFs' anatomy, using image processing on the real-time 2D fluoroscopic images. The haptic feedbacks are then rendered on to the master device depending on the interaction with attractive and repulsive, guidance and forbidden region VFs.

RESULTS

A feasibility study in the laboratory environment is performed by using a webcam as an image acquisition device and a phantom-based coronary vessel model. The subsequent statistical analysis shows that, on an average, a decrease of approx. 37% in task completion time is observed with haptic feedback. Moreover, haptic guidance is found effective for most difficult branch, whereas there is a minimal significance of such haptics for the easiest branch.

CONCLUSIONS

The proposed haptic guidance procedure may assist cardiologists for an efficient and effective guidewire navigation during a surgical procedure. The cutaneous haptics (vibration feedback) is found more helpful in coronary interventions compared with kinesthetic haptics (force feedback).

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.

Design and Performance Evaluation of a Novel Vascular Robotic System for Complex Percutaneous Coronary Interventions

The robotic-assisted percutaneous coronary intervention is an emerging technology with great potential to solve the shortcomings of existing treatments. However, the current robotic systems can not manipulate two guidewires or ballons/stents simultaneously for coronary bifurcation lesions. This paper presents VasCure, a novel bio-inspired vascular robotic system, to deliver two guidewires and stents into the main branch and side branch of bifurcation lesions in sequence. The system is designed in master-slave architecture to reduce occupational hazards of radiation exposure and orthopedic injury to interventional surgeons. The slave delivery device has one active roller and two passive rollers to manipulate two interventional devices. The performance of the VasCure was verified by in vitro and in vivo animal experiments. In vitro results showed the robotic system has good accuracy to deliver guidewires and the maximum error is 0.38mm. In an animal experiment, the interventional surgeon delivered two guidewires and balloons to the left circumflex branch and the left anterior descending branch of the pig, which confirmed the feasibility of the vascular robotic system.

Design and experimental evaluation of an automated catheter operating system

Manual catheter-based interventions (CBIs) suffer from exposure of the interventionalists to X-ray, and dependence of their performance on the expertise and fatigue level of the interventionalists. Robot-assisted catheterization systems (RACS) have been introduced in recent years to improve the efficiency of CBIs; however, using them is still associated with some difficulties such as set-up dependency to a specific type of intervention instrument, not being portable, and offering limited options of operation modes. The objective of this research is to develop a new RACS to address these shortcomings. We propose Althea II as an improvement for our previously introduced RACS, Althea I. Althea II is designed for both research purposes and clinical applications including catheter-based cardiovascular interventions. Althea II benefits from a novel structural design leading to a significantly reduced weight and making the device inclusive for a broader range of intervention instruments. Also, a tip detection algorithm is developed and integrated into the graphical user interface (GUI) to enable image-based navigation, and accordingly, fully automatic navigation. Althea II has improved the outcome of catheter-based interventions by increased accuracy and precision of the intervention. The system can navigate the catheter tip to a designated target with an accuracy higher than 90% in both velocity and positioning mode. The device is associated with an upgraded GUI equipped with a strong tip detection algorithm with an accuracy of 0.05 mm. Moreover, Althea II gains from a quicker assembly time (20 minutes, which equals five times faster). The independency from specific catheters, several modes of function, an imaged-based feedback control, portability, and a remote function should allow operation even from beginners and reduce X-ray exposure. The preliminary research studies verified the accuracy and repeatability of Althea II, demonstrated the feasibility and applicability of using the set-up in multiple applications, and highlighted the improved set-up capabilities over the currently available RACS.

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.