First-in-Human Evaluation of a Novel Robotic-Assisted Coronary Angioplasty System

Safety and Feasibility of Robot-Assisted Percutaneous Coronary Intervention Using the AVIAR 2.0 System: A Prospective, Multi-Center, Single-Arm, Open, Investigator-Initiated, Post-Approval Clinical Trial

BACKGROUND AND OBJECTIVES

Traditional manual percutaneous coronary intervention (PCI) exposes operators to significant radiation and physical stress. The recently developed Advanced Vascular Intervention Assist Robot (AVIAR) 2.0 system in South Korea aimed to overcome these issues by evaluating its safety and feasibility in a clinical setting.

METHODS

The study enrolled patients with stable angina from 2 medical centers. Single-vessel de novo lesions were treated using the AVIAR 2.0 system. The primary endpoints were technical success (using the AVIAR system for PCI devices, including guidewires, balloon catheters, and stents, without switching to manual) and clinical success (<30% residual stenosis in the treated lesion and no major cardiovascular events within 48 hours or before discharge). Secondary endpoints included operator radiation exposure and procedural time. Safety was assessed using treatment-emergent adverse events.

RESULTS

Twenty patients (mean age, 63.9±8.5 years, 70% male) underwent robot-assisted PCI for lesions mainly in the left anterior descending artery and right coronary artery, with 95% (19/20) classified as B2/C lesions. The average robotic procedural time was 23:06±05:55 minutes. Technical success was 100%, with no need for manual conversion. Clinical success was 100%, with no major complications until discharge. Operator effective radiation dose was reduced by 84% compared to table effective doses.

CONCLUSIONS

The AVIAR 2.0 system appears to be a safe and effective adjunct to manual PCI, enhancing procedural efficiency and reducing operator radiation exposure. These findings support the use of robotics in coronary interventions and suggest a promising future for minimally invasive cardiac procedures.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05981859.

Robotics for Neuroendovascular Therapy

In the field of abdominal and pelvic surgery, endoscopic procedures have increasingly utilized robotic surgery, including the da Vinci system (Intuitive Surgical, Sunnyvale, CA, USA). Unlike robotic surgery in these fields, endovascular treatment involves simple movements such as pushing and pulling or twisting catheters and wires, allowing for the creation of relatively straightforward robotic systems that can replicate these endovascular procedures. Recently, there have been clinical applications of this technology in coronary arteries. However, when applying it to cerebral vessels, which have significant curvature and fragility, it is essential to develop a system that can adequately assess and reflect the physical stress on the vessel wall. Furthermore, remote surgery (telesurgery) performed by specialists is one of the most sought-after applications of robotics, but issues remain due to poor communication environments, leading to delays in operation and control difficulties. Additionally, there are ethical concerns regarding the responsibility for adverse events related to robotic surgery, highlighting the urgent need for the establishment of guidelines.

Impact of Robotic Percutaneous Coronary Intervention (R-PCI) With and Without CCTA-Guidance on Clinical Outcomes and Hospital Economics: A Single Center Registry

BACKGROUND

Several studies have confirmed the safety and efficacy of robotic assisted coronary interventions for simple and complex coronary lesions. However, in the real-world clinical setting the currently available evidence is still inconclusive with regard to clinical outcomes. In terms of financial sustainability, the emerging use of pre-PCI Coronary Computed Tomography Angiography (CCTA) may potentially impact the overall patient journey and related costs. However, the role of CCTA guidance in elective robotic-assisted revascularizations and its potential impact on hospital economics has never been investigated. Therefore, we aimed to assess the clinical impact of R-PCI according to procedural complexity and its potential financial sustainability when integrated with CCTA guidance.

METHODS

Major adverse cardiovascular events (MACE) at the latest clinical follow-up available have been prospectively evaluated in a single center cohort of 111 patients undergoing elective R-PCI (CorPath, Corindus GRX Robotic Drive, Boston, MA). The study population was subsequently divided into two groups according to either the median Syntax Score (SS = 14) as a surrogate of procedural complexity or the adoption of CCTA-guidance. Additionally, both periprocedural and in-hospital outcomes have been investigated in the overall cohort and in the subgroups.

RESULTS

Overall, MACE occurred in 5.4% of the patients at a median follow-up of 309 days. Procedural complexity was associated with significantly longer procedural time and radiation exposure (SS ≥ 14: 94.5 ± 32.1 vs. 78.7 ± 25.5 min, p = 0.011, and 32.7 ± 30.9 vs. 22.5 ± 19.8 mSv, p = 0.010, respectively), but not with increased in-hospital and long-term clinical outcomes. Additionally, patients undergoing CCTA-guided R-PCI had a significantly higher rate of same-day-discharge (SDD-64.6% vs. 44.2% respectively, p = 0.034) than those without CCTA support.

CONCLUSION

R-PCI appears safe and effective regardless the procedural complexity. Moreover, the integration of robotics and CCTA-guidance appears to have beneficial impact on hospital economics by optimizing resource utilization and improving patient selection for percutaneous revascularization.

A Novel Endovascular Robotic System for Treatment of Lower Extremity Peripheral Arterial Disease: First-in-Human Experience

BACKGROUND

To assess the feasibility and first-in-human experience of a novel endovascular robotic system for treatment of lower extremity peripheral arterial disease (PAD).

METHODS

Between November 2021 and January 2022, consecutive patients with obstructive lower extremity PAD and claudication (Rutherford 2-5) with >50% stenosis demonstrated on angiography were enrolled in this study. Lower extremity peripheral arterial intervention was performed using the endovascular robotic system, which consisted of a bedside unit and an interventional console. The primary endpoints were technical success, defined as the successful manipulation of the lower extremity peripheral arterial devices using the robotic system, and safety. The secondary endpoints were clinical success, defined as 50% residual stenosis at the completion of the robot-assisted procedure without major adverse cardiac events and radiation exposure.

RESULTS

In total, 5 patients with PAD were enrolled in this study (69.2±6.0 years; 80% men). The novel endovascular robotic system successfully completed the entire procedure of endovascular treatment of lower extremity PAD. Conversion to manual operation, including advancement, retracement, rotation of the guidewires, catheters, sheaths, deployment, and release of the balloons and stent grafts, was not necessary. We achieved the criteria for clinical procedural and technical success in all patients. No deaths, myocardial infarctions, or ruptures occurred in the period up to 30 days after the procedure, and no device-related complications were observed. The robotic system operator had 97.6% less radiation exposure than that at the procedure table, with a mean of 1.40±0.49 μGy.

CONCLUSIONS

This study demonstrated the safety and feasibility of the robotic system. The procedure reached technical and clinical performance metrics and resulted in significantly lower radiation exposure to the operators at the console compared with that at the procedure table.

CLINICAL IMPACT

There were some reports about several robotic systems used in the peripheral arterial disease, but no robotic system was able to perform entire procedure of endovascular treatment of lower extremity peripheral arterial disease (PAD).To solve this problem, we designed a remote-control novel endovascular robotic system. It was the first robotic system that can perform entire procedure of endovascular treatment of PAD worldwide. A novelty retrieval report about this is provided in the supplementary materials.The robotic system is compatible with all commercial endovascular surgical devices currently available in the market, including guidewires, catheters and stent delivery systems. It can perform all types of motion, such as forward, backward, and rotation to meet the requirements of all types of endovascular procedures. During the operation, the robotic system can perform these operations in a fine-tuned manner, so it is easy to cross the lesions, which is the key factor influencing the success rate of the operation. In addition, the robotic system can effectively reduce the exposure time to radiation, thereby reducing the risk of occupational injury.

Feasibility of robotic neuroendovascular surgery

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Features and Limitations of Robotically Assisted Percutaneous Coronary Intervention (R-PCI): A Systematic Review of R-PCI

Background: Ischaemic heart disease is one of the major drivers of cardiovascular death in Europe. Since the first percutaneous coronary intervention (PCI) in 1977, developments and innovations in cardiology have made PCI the treatment of choice for stenotic coronary artery disease. To address the occupational hazards related to chronic exposure to radiation and wear and tear from heavy lead-based radioprotective aprons, the concept of robotically assisted PCI (R-PCI) was introduced in 2005. Aim: To explore the features and limitations of R-PCI, we first discuss the concept and evolution of R-PCI platforms and then systematically review the available clinical data. Methods: A systematic review has been performed across the Pubmed, Embase and Cochrane databases in order to assess the efficacy and safety of R-PCI. Secondary endpoints, such as operator and patient exposure to radiation, contrast volume used and procedural time, were assessed when available. Results: In selected patients, R-PCI provides high technical and clinical success rates, ranging from 81 to 98.8% and from 93.3 to 100%, respectively. In-hospital and 1-year MACE rates ranged from 0 to 10.4% and 4.8 to 10.5%, respectively. R-PCI is able to significantly reduce the operator's exposure to radiation. Further research analysing the patient's and cath lab staff's exposure to radiation is needed. Therapy escalation with R-PCI seems to be limited to complex lesions. R-PCI procedures add approximately 10 min to the procedural time. Conclusions: The efficacy and safety of R-PCI have been proven, and R-PCI is able to significantly reduce occupational hazards for the first operator. The lack of adoption in the community of interventional cardiologists may be explained by the fact that current generations of R-PCI platforms are limited by their incompatibility with advanced interventional devices and techniques needed for escalation in complex interventions.

Narrative review of latest research progress about robotic percutaneous coronary intervention

Robotic percutaneous coronary intervention (R-PCI) is a novel technology in which operators can manipulate guidewires and catheter devices in interventional cardiology. This approach provides great benefits to interventional cardiologists in terms of reducing both radiation exposure and orthopedic injuries. Several large, high-quality cohort studies have confirmed the short-term safety and high technical success rate of R-PCI. However, randomized long-term data are still needed before adopting them as part of standard coronary interventions. Furthermore, tele-stenting for complex coronary lesions has significant potential for R-PCI. We need to overcome the present relevant challenges for its application such as inherent delays, bedside care for unstable patients from R-PCIs to manual PCIs (M-PCIs), incompatibility for a thrombus aspiration catheter and heavily calcified lesions. There is a great future in laboratory workflow teams, 3D-printed anatomical models and multiple joint collaborative control algorithms. This narrative review summarizes the latest developments in R-PCI, with a focus on developments in robotic technology, and discusses the current and future potential use of R-PCI in clinical practice globally.

One-year outcome of robotical vs. manual percutaneous coronary intervention

BACKGROUND

Robotic-assisted percutaneous coronary intervention (R-PCI) is a promising technology for optimizing the treatment of patients with coronary heart disease. For a better understanding of the potential of R-PCI in clinical routine compared to conventional manual PCI (M-PCI) both initial treatment success of the index procedure and long-term outcome have to be analysed.

METHODS

Prospective evaluation from the FRiK (DRKS00023868) registry of all R-PCI cases with the CorPath GRX Cardiology by Siemens Healthineers and Corindus in the Freiburg University Heart Center between 04/2022 and 03/2023. Index procedure success and safety, radiation dose of patients and personnel, and 1-year outcome will be reported. Findings will be compared to a prospective control group of M-PCI patients treated by the same team of interventionalists during the same observation period.

RESULTS

Seventy patients received R-PCI and were included in the registry. PCI success rate was 100%, with 19% requiring manual assistance. No complications (MACE-major adverse cardiovascular events) occurred. Compared with 70 matched-pair M-PCI patients, there was a higher median procedural time (103 min vs. 67 min, p < 0.001) and fluoroscopy time (18 min vs. 15 min, p = 0.002), and more contrast volume was used (180 ml vs. 160 ml, p = 0.041) in R-PCI vs. M-PCI patients. However, there was no significant difference of the dose-area product (4062 vs. 3242 cGycm2, p = 0.361). One year after the intervention, there was no difference in mortality, rehospitalisation, unscheduled PCI or target vessel failure. Health-related quality of life evaluation 6 and 12 months after the index procedure (NYHA, CCS, SAQ7 and EQ-5D-5L) was similar in both groups.

CONCLUSION

R-PCI is feasible and safe. Compared to M-PCI, index procedure success rate is high, safety profile is favourable, and manual assistance was required in only few cases. At 1-year follow-up results for R-PCI vs. M-PCI considering mortality, rehospitalisation, morbidity and target vessel failure were equal.

Real time eye dose reduction in fluoroscopy with auditory and visual feedback dosimeter through swine model experiments

This paper proposes measurement and reduction of eye dose in real time for the physician and the assistant performing fluoroscopy guided arterial puncture. Eye dose rates were measured for 30 fluoroscopy-guided punctures of bilateral femoral arteries in pigs. Fifteen fluoroscopy-guided punctures were performed using real time radiation dosimeter without auditory and visual feedback and other fifteen punctures were done using real time radiation dosimeter with visual and auditory feedback worn on forehead by an interventional cardiologist having experience of more than 10 years. The mean radiation dose rate for eyes of physician during arterial puncturing with real time radiation dosimeter with auditory feedback was 0.07 mSv/h (n = 15) whereas it was 0.18 mSv/h (n = 15) without visual and auditory feedback. The percentage of reduction with the device was 61% for eyes. In case of assistant the reduction was 33% for eyes (n = 15). The real time visual and auditory feedback dosimeter has reduced the eye dose rate of the physician and assistant and also helped him staying away from the X-ray source. Real time radiation dosimeters can be an effective tool to measure and reduce the dose to the eyes. The radiation eye dose rate for physician and assistant was significantly reduced by using real time radiation dosimeter with visual and auditory feedback. The real time radiation dosimeter not only helps in measuring but also help in minimizing the radiation dose rate for the physician and assistant in real time.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

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.

Improved precise guidewire delivery of a cardiovascular interventional surgery robot based on admittance control

PURPOSE

The development of cardiovascular interventional surgery robots can realize master-slave interventional operations, which will effectively solve the problem of surgeons being injured by X-ray radiation. The delivery accuracy and safety of interventional instruments such as guidewire are the most important issues in the development of robotic systems. Most of the current control methods are position control or force feedback control, which cannot take into account delivery accuracy and safety.

METHODS

A cardiovascular interventional surgery robotic system integrated force sensors is developed. A novel force/position controller, which includes a radial basis function neural networks-based inner loop position controller and a force-based admittance outer loop controller, is proposed. Furthermore, a series of simulations and vascular model experiments are carried out to demonstrate the feasibility and accuracy of the proposed controller.

RESULTS

The designed cardiovascular interventional robot is flexible to enter the target vessel branch. Experimental results indicate that the proposed controller can effectively improve the delivery accuracy of the guidewire and reduce the contact force with the vessel wall.

CONCLUSIONS

The proposed controller based on radial basis function neural network and admittance control is effective in improving delivery accuracy and reducing contact force. The algorithm needs to be further validated in vivo experiments.

Latest Developments in Robotic Percutaneous Coronary Interventions

Since the first robotic-assisted percutaneous coronary intervention procedure (R-PCI) was performed in 2004, there has been a steady evolution in robotic technology, combined with a growth in the number of robotic installations worldwide and operator experience. This review summarises the latest developments in R-PCI with a focus on developments in robotic technology, procedural complexity, tele-stenting and training methods, which have all contributed to the global expansion in R-PCI.

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.

Learning-Based Multimodal Information Fusion and Behavior Recognition of Vascular Interventionists' Operating Skills

The operating skills of vascular interventionists have an important impact on the effect of surgery. However, current research on behavior recognition and skills learning of interventionists' operating skills is limited. In this study, an innovative deep learning-based multimodal information fusion architecture is proposed for recognizing and analyzing eight common operating behaviors of interventionists. An experimental platform integrating four modal sensors is used to collect multimodal data from interventionists. The ANOVA and Manner-Whitney tests is used for relevance analysis of the data. The analysis results demonstrate that there is almost no significant difference ( p <0.001) between the actions related to the unimodal data, which cannot be used for accurate behavior recognition. Therefore, a study of the fusion architecture based on the existing machine learning classifier and the proposed deep learning fusion architecture is carried out. The research findings indicate that the proposed deep learning-based fusion architecture achieves an impressive overall accuracy of 98.5%, surpassing both the machine learning classifier (93.51%) and the unimodal data (90.05%). The deep learning-based multimodal information fusion architecture proves the feasibility of behavior recognition and skills learning of interventionist's operating skills. Furthermore, the application of deep learning-based multimodal fusion technology of surgeon's operating skills will help to improve the autonomy and intelligence of surgical robotic systems.

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

AIM

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

METHODS

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

RESULTS

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

Evaluation of the R-One robotic system for percutaneous coronary intervention: the R-EVOLUTION study

BACKGROUND

R-One is a robotic percutaneous coronary intervention (PCI) system (CE mark 2019) designed to reduce operator radiation exposure, improve ergonomics, and accurately navigate, position, and deliver guidewires/devices during PCI.

AIMS

We aimed to evaluate the safety and efficacy of the R-One system for PCI.

METHODS

The European multicentre prospective R-EVOLUTION study included patients with a de novo coronary artery stenosis (length <38 mm, reference diameter 2.5-4.0 mm) undergoing stent implantation. Patients with recent ST-segment elevation myocardial infarction, ostial or left main lesion, bifurcation, severe tortuosity, or calcification were excluded. Clinical success was defined as the absence of major intraprocedural complications. Technical success was defined as the successful advancement and retraction of all PCI devices (guidewires/balloon/stents) without total manual conversion. Radiation exposure to patients, to a simulated manual operator, and to robotic PCI operators was measured.

RESULTS

Sixty-two consecutive patients (B2/C lesions: 25.0% [16/64]) underwent robotic PCI. Radial access was used in 96.8% (60/62) of procedures. The mean robotic procedure duration was 19.9±9.6 min and the mean fluoroscopy time was 10.3±5.4 min. Clinical success was 100% with no complications at 30 days. Technical success was 95.2% (59/62). Total manual conversion was required in 4.8% (3/62) cases, with 1 case directly related to the robotic system. Operator radiation exposure was reduced by 84.5% under and 77.1% on top of the lead apron, compared to doses received on the patient table.

CONCLUSIONS

This study suggests that robotic PCI using R-One is safe and effective with markedly lower radiation exposure to the operator. Further studies are needed to evaluate R-One in larger patient populations with more complex lesions. (ClinicalTrials.gov: NCT04163393).

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.

Multi-mode information fusion navigation system for robot-assisted vascular interventional surgery

BACKGROUND

Minimally invasive vascular intervention (MIVI) is a powerful technique for the treatment of cardiovascular diseases, such as abdominal aortic aneurysm (AAA), thoracic aortic aneurysm (TAA) and aortic dissection (AD). Navigation of traditional MIVI surgery mainly relies only on 2D digital subtraction angiography (DSA) images, which is hard to observe the 3D morphology of blood vessels and position the interventional instruments. The multi-mode information fusion navigation system (MIFNS) proposed in this paper combines preoperative CT images and intraoperative DSA images together to increase the visualization information during operations.

RESULTS

The main functions of MIFNS were evaluated by real clinical data and a vascular model. The registration accuracy of preoperative CTA images and intraoperative DSA images were less than 1 mm. The positioning accuracy of surgical instruments was quantitatively assessed using a vascular model and was also less than 1 mm. Real clinical data used to assess the navigation results of MIFNS on AAA, TAA and AD.

CONCLUSIONS

A comprehensive and effective navigation system was developed to facilitate the operation of surgeon during MIVI. The registration accuracy and positioning accuracy of the proposed navigation system were both less than 1 mm, which met the accuracy requirements of robot assisted MIVI.

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.

First-in-human evaluation of an independently developed Chinese robot-assisted system for percutaneous coronary intervention

BACKGROUND

Several studies have proved the safety and feasibility of robot-assisted percutaneous coronary intervention (PCI) in reducing the occupational hazards of interventionists while achieving precision medicine. However, an independently developed robot-assisted system for PCI in China has not yet emerged. This study aimed to evaluate the safety and feasibility of a robot-assisted system for elective PCI in China.

METHODS

This preclinical trial included 22 experimental pigs and preliminarily supported the safety and feasibility of the ETcath200 robot-assisted system for PCI. Then, eleven patients with coronary heart disease who met the inclusion criteria and had clinical indications for elective PCI were enrolled. PCI was performed using a robot-assisted system. The primary outcomes were clinical success (defined as visual estimated residual stenosis < 30% after PCI and no major adverse cardiovascular events during hospitalization and within 30 days after PCI) and technical success (defined as the ability to use the robot-assisted system to complete PCI successfully without conversion to the traditional manual PCI).

RESULTS

Eleven patients were included in this clinical trial. A drug-eluting stent with a diameter of 3 mm (interquartile range: 2.75-3.5 mm) and a length of 26 mm (interquartile range: 22-28 mm) was deployed in all patients. The clinical success rate was 100%, with no PCI-related complications and no in-hospital or 30-day major adverse cardiovascular events, and the technical success rate was 100%.

CONCLUSIONS

The results strongly suggest that the use of the independently developed robot-assisted system in China for elective PCI is feasible, safe, and effective.

Robotics in neurointerventional surgery: a systematic review of the literature

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Safety and Efficacy of Robotic-Assisted PCI

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

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.

Telerobotic Endovascular Interventions and Their Potential for Cerebrovascular Treatment

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

Robotics for neuroendovascular intervention: Background and primer

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

A Novel Robotic Control System Mimics Doctor’s Operation to Assist Percutaneous Coronary Intervention

Objectives: The use of current robotic systems to assist in percutaneous coronary intervention (PCI) fundamentallydiffers from performing conventional PCI. To overcome this problem, we developed a novel master-slave roboticcontrol system to assist in PCI, and evaluated its safety and feasibility in the delivery and manipulation of coronaryguidewires in vitro and in vivo.Methods: The novel robotic assist PCI system is composed of three parts: 1) a master actuator, which imitates thetraditional torque used by surgeons in conventional PCI, 2) a slave actuator, including a guidewire delivery system andforce monitoring equipment, and 3) a local area network based communication system.Results: The experiment was performed in six pigs. Both robotic and manual control completed the operation with no device- or procedure-associated complications. An experienced interventional cardiologist who was a first-time userof the novel robotic PCI system was able to advance the guidewire into a distal branch of a coronary artery within asimilar time to that required with the manual procedure.Conclusion: This early in vivo experiment with the novel robotic assisted PCI control system demonstrated that its feasibility, safety, and procedural effectiveness are comparable to those of manual operation. The novel robotic-assisted PCI control system required significantly less time to learn than other currently available systems.

Robot-assisted carotid artery stenting: outcomes, safety, and operational learning curve

OBJECTIVE

Over the past 2 decades, robots have been increasingly used in surgeries to help overcome human limitations and perform precise and accurate tasks. Endovascular robots were pioneered in interventional cardiology, however, the CorPath GRX was recently approved by the FDA for peripheral vascular and extracranial interventions. The authors aimed to evaluate the operational learning curve for robot-assisted carotid artery stenting over a period of 19 months at a single institution.

METHODS

A retrospective analysis of a prospectively maintained database was conducted, and 14 consecutive patients who underwent robot-assisted carotid artery stenting from December 2019 to June 2021 were identified. The metrics for proficiency were the total fluoroscopy and procedure times, contrast volume used, and radiation dose. To evaluate operator progress, the patients were divided into 3 groups of 5, 4, and 5 patients based on the study period.

RESULTS

A total of 14 patients were included. All patients received balloon angioplasty and stent placement. The median degree of stenosis was 95%. Ten patients (71%) were treated via the transradial approach and 4 patients (29%) via the transfemoral approach, with no procedural complications. The median contrast volume used was 80 mL, and the median radiation dose was 38,978.5 mGy/cm2. The overall median fluoroscopy and procedure times were 24.6 minutes and 70.5 minutes, respectively. Subgroup analysis showed a significant decrease in these times, from 32 minutes and 86 minutes, respectively, in group 1 to 21.9 minutes and 62 minutes, respectively, in group 3 (p = 0.002 and p = 0.008, respectively).

CONCLUSIONS

Robot-assisted carotid artery stenting was found to be safe and effective, and the learning curve for robotic procedures was overcome within a short period of time at a high-volume cerebrovascular center.

Safety and feasibility of robotic assisted percutaneous coronary intervention compared to standard percutaneous coronary intervention- a systematic review and meta-analysis

Objective

Robotically assisted PCI offers a great alternative to S–PCI. This has gained even more relevance during the COVID-19 pandemic era however safety of R–PCI compared to S–PCI has not been studied well. This study explores the safety and efficacy of robotically assisted PCI (R–PCI) compared to standard PCI (S–PCI) for the treatment of coronary artery disease (CAD).

Methods

PubMed, Scopus, Ovid, and Google scholar databases were searched for studies comparing R–PCI to S–PCI. Outcomes included clinical success, procedure time, fluoroscopy time, contrast use and radiation exposure.

Results

Theauthors included 5 studies comprising 1555 patients in this meta-analysis. Clinical success was comparable in both arms (p = 0.91). Procedure time was significantly longer in R–PCI group (risk ratio: 5.52, 95% confidence interval: 1.85 to 9.91, p = 0.003). Compared to S–PCI, patients in R–PCI group had lower contrast use (meandifference: −19.88, 95% confidence interval: −21.43 to −18.33, p < 0.001), fluoroscopy time (mean difference:-1.82, 95% confidence interval: −3.64 to −0.00, p = 0.05) and radiation exposure (mean difference:-457.8, 95% confidence interval: −707.14 to −208.14, p < 0.001).

Conclusion

R–PCI can achieve similar success as S–PCI at the expense of longer procedural times. However, radiation exposure and contrast exposure were lower in the R–PCI arm.

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.

Robotics, imaging, and artificial intelligence in the catheterisation laboratory

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

An MR-Safe Endovascular Robotic Platform: Design, Control, and Ex-Vivo Evaluation

OBJECTIVE

Cardiovascular diseases are the most common cause of global death. Endovascular interventions, in combination with advanced imaging technologies, are promising approaches for minimally invasive diagnosis and therapy. More recently, teleoperated robotic platforms target improved manipulation accuracy, stabilisation of instruments in the vasculature, and reduction of patient recovery times. However, benefits of recent platforms are undermined by a lack of haptics and residual patient exposure to ionising radiation. The purpose of this research was to design, implement, and evaluate a novel endovascular robotic platform, which accommodates emerging non-ionising magnetic resonance imaging (MRI).

METHODS

We proposed a pneumatically actuated MR-safe teleoperation platform to manipulate endovascular instrumentation remotely and to provide operators with haptic feedback for endovascular tasks. The platform task performance was evaluated in an ex vivo cannulation study with clinical experts ( N = 7) under fluoroscopic guidance and haptic assistance on abdominal and thoracic phantoms.

RESULTS

The study demonstrated that the robotic dexterity involving pneumatic actuation concepts enabled successful remote cannulation of different vascular anatomies with success rates of 90%-100%. Compared to manual cannulation, slightly lower interaction forces between instrumentation and phantoms were measured for specific tasks. The maximum robotic interaction forces did not exceed 3N.

CONCLUSION

This research demonstrates a promising versatile robotic technology for remote manipulation of endovascular instrumentation in MR environments.

SIGNIFICANCE

The results pave the way for clinical translation with device deployment to endovascular interventions using non-ionising real-time 3D MR guidance.

A Magnetorheological Fluids-Based Robot-Assisted Catheter/Guidewire Surgery System for Endovascular Catheterization

A teleoperated robotic catheter operating system is a solution to avoid occupational hazards caused by repeated exposure radiation of the surgeon to X-ray during the endovascular procedures. However, inadequate force feedback and collision detection while teleoperating surgical tools elevate the risk of endovascular procedures. Moreover, surgeons cannot control the force of the catheter/guidewire within a proper range, and thus the risk of blood vessel damage will increase. In this paper, a magnetorheological fluid (MR)-based robot-assisted catheter/guidewire surgery system has been developed, which uses the surgeon’s natural manipulation skills acquired through experience and uses haptic cues to generate collision detection to ensure surgical safety. We present tests for the performance evaluation regarding the teleoperation, the force measurement, and the collision detection with haptic cues. Results show that the system can track the desired position of the surgical tool and detect the relevant force event at the catheter. In addition, this method can more readily enable surgeons to distinguish whether the proximal force exceeds or meets the safety threshold of blood vessels.

Latest Developments in Robotic Percutaneous Coronary Intervention

Interventional cardiovascular medicine has seen constant progress over the last few decades. Since the first angiograms and percutaneous transluminal coronary angioplasty were carried out, this progress has been tremendous and has led to a substantial decline in cardiovascular morbidity and mortality. The purpose of this article is to report and review the latest developments and evidence in robotics-assisted percutaneous coronary intervention (rPCI) and its potential future applications, opportunities, and limitations. Contemporary evidence shows that rPCI can lead to a significant reduction in radiation exposure as well as medical hazards for cardiologists. Rates of device and procedural success remain high and there is no evidence of a disadvantage for the patient. The accuracy of implantation with a reduced geographic mismatch is a further advantage that can result in a higher quality of treatment. Even in complex coronary lesions and procedures, rPCI seems to be safe and efficient. The latest developments include telestenting over hundreds of kilometers from a remote platform. Currently, the main limitations are the absence of large-scale randomized trials for the valid assessment of the benefits and disadvantages of rPCI as well as the technical limitations of the currently available rPCI systems. rPCI is a forward-looking innovation in cardiology that is applicable to a wide range of coronary interventions. Despite the present lack of knowledge and the limited data concerning the outcome for the patient, the available literature reveals promising results that should lead to improvements for physicians and patients.

Development status of telesurgery robotic system

As an emerging field, telesurgery robotic system is changing the traditional medical mode and can delivery remote surgical treatment anywhere in the world. Advances in telesurgery robotic technology achieve the remote control beyond the current limitation of distance and special medical environment. This review introduces the development history, the current status and the potential in future of the telesurgery robotic system. In addition, it presents the construction of control platform and the application, especially in trauma treatment, as well as the challenge in clinic.

Iterative Improvement and Marginal Gains in Coronary Revascularisation: Is Robot-assisted Percutaneous Coronary Intervention the New Hope?

Percutaneous coronary intervention (PCI) has undergone a rapid and adaptive evolution since its introduction into clinical practice more than 40 years ago. It is the most common mode of coronary revascularisation in use, with the scope, breadth and constellation of disease being treated increasing markedly over time. This has principally been driven by improvements in technology, engineering and training in the field, which has facilitated more complex PCI procedures to be undertaken safely. Robot-assisted PCI represents the next paradigm shift in contemporary PCI practice. It has the ability to enhance procedural accuracy for the patient while improving radiation safety and ergonomics for the operator. This state-of-the-art review outlines the current position and future potential of robot-assisted PCI.

Neuroendovascular-specific engineering modifications to the CorPath GRX Robotic System

OBJECTIVE

The aim of this study was to evaluate new, neuroendovascular-specific engineering and software modifications to the CorPath GRX Robotic System for their ability to support safer and more effective cranial neurovascular interventions in a preclinical model.

METHODS

Active device fixation (ADF) control software, permitting automated manipulation of the guidewire relative to the microcatheter, and a modified drive cassette suitable for neuroendovascular instruments were the respective software and hardware modifications to the current CorPath GRX robot, which was cleared by the FDA for percutaneous coronary and peripheral vascular intervention. The authors then trialed the modified system in a live porcine model with simulated neuroendovascular pathology. Femoral access through the aortic arch to the common carotid artery was accomplished manually (without robotic assistance), and the remaining endovascular procedures were performed with robotic assistance. The system was tested for the enhanced ability to navigate and manipulate neurovascular-specific guidewires and microcatheters. The authors specifically evaluated the movement of the wire forward and backward during the advancement of the microcatheter.

RESULTS

Navigation of the rete mirabile and an induced aneurysm within the common carotid artery were successful. The active device fixation feature enabled independent advancement and retraction of the guidewire and working device relative to the microcatheter. When ADF was inactive, the mean forward motion of the guidewire was 5 mm and backward motion was 0 mm. When ADF was active, the mean forward motion of the guidewire was 0 mm and backward motion was 1.5 mm. The modifications made to the robotic cassette enabled the system to successfully manipulate the microcatheter and guidewire safely and in a manner more suited to neuroendovascular procedures than before. There were no occurrences of dissection, extravasation, or thrombosis.

CONCLUSIONS

The robotic system was originally designed to navigate and manipulate devices for cardiac and peripheral vascular intervention. The current modifications described here improved its utility for the more delicate and tortuous neurovascular environment. This will set the stage for the development of a neurovascular-specific robot.

Force feedback controls of multi-gripper robotic endovascular intervention: design, prototype, and experiments

PURPOSE

Robotic endovascular intervention system (REIS) has the advantages of telemanipulation without radiation damage, precise location, and isolation of hand quiver. However, current REIS lacks a force feedback, which leads to high clinical risks. For the high operational safety of remote operations, this research proposes a force feedback control method for a novel manipulator with multi-grippers and develops a prototype to verify its expected telepresence.

METHODS

A high-resolution force sensor is used to acquire and transmit the intervention resistance force to the control handle. When the handle is translated or rotated, a loading mechanism composed of a servomotor, a screw pair, a spring, and friction roller generates the resistance force transmitted to the doctor's hand through the handle. A force/displacement hybrid control and PID control algorithm are used for the smaller feedback force error and lower delay.

RESULTS

This manipulator and its control handle are tested in the simulated catheter and vascular cases. The experiments show that force feedback precision can reach 0.05 N and the delay is not more than 50 ms, and the bandwidth is 9 Hz@-3 dB.

CONCLUSION

The proposed force feedback method can recreate resistance force from the intervention devices. The control model is valid with higher precision and wide bands, which has laid foundations to the application of REIS in clinic.

Current utilization and future directions of robotic-assisted endovascular surgery

INTRODUCTION

Endovascular surgery has become the standard of care to treat most vascular diseases using a minimally invasive approach. The CorPath system further enhances the potential and enables surgeons to perform robotic-assisted endovascular procedures in interventional cardiology, peripheral vascular surgery, and neurovascular surgery. With the introduction of this technique, the operator can perform multiple steps of endovascular interventions outside of the radiation field with high precision movements even from long-geographical distances.

AREAS COVERED

The first and second-generation CorPath systems are currently the only commercially available robotic devices for endovascular surgery. This review article discusses the clinical experiences and outcomes with the robot, the advanced navigational features, and the results with recent hardware and software modifications, which enables the use of the system for neurovascular interventions, and long-distance interventional procedures.

EXPERT OPINION

A high procedural success was achieved with the CorPath robotic systems in coronary and peripheral interventions, and the device seems promising in neurovascular procedures. More experience is needed with robotic neurovascular interventions and with complex peripheral arterial cases. In the future, long-distance endovascular surgery can potentially transform the management and treatment of acute myocardial infarction and stroke, with making endovascular care more accessible for patients in remote areas.

A Novel Universal Endovascular Robot for Peripheral Arterial Stent-Assisted Angioplasty: Initial Experimental Results

BACKGROUND

The bottleneck of the development of endovascular interventional robot is that it cannot fully adapt to commercialized endovascular devices, such as guidewires, catheters, and stents, and cannot complete the entire procedure of endovascular treatment, for instance, stent implantation. The purpose of this study is to evaluate whether the novel universal endovascular interventional robot can adapt to different commercialized endovascular devices and accomplish the entire procedure of endovascular treatment of peripheral vascular disease.

METHODS AND MATERIAL

The novel universal endovascular interventional robot consists of 2 components: a master surgeon console and a robotic platform with 4 manipulators. An adult pig was served as the experimental animal. Bilateral iliac artery stent implantation was performed on the pig by the endovascular interventional robot using commercialized guidewires, catheters, and stent delivery systems.

RESULTS

The novel universal endovascular interventional robot can adapt to commercialized endovascular devices, and most interventional procedures, such as insertion, withdrawal, and rotating, can be done through remote control. By coordinating multiple manipulators, complex actions such as superselection, crossing action, or implantation of self-expanding bare stent can be realized. The entire procedure took about 50 minutes, and the total exposure time of the surgeon was less than 1 minute. Postoperative angiography showed that the position of the stent grafts was accurate. The procedure was stable without any stent or surgical-related complications.

CONCLUSION

The novel universal endovascular interventional robot can realize peripheral arterial stent-assisted angioplasty with commercialized devices. Through the design improvement, the problem related to stent implantation is solved, and the remote operation is realized throughout the endovascular procedure.

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.

Endovascular robotic: feasibility and proof of principle for diagnostic cerebral angiography and carotid artery stenting

Background

Robots in surgery aid in performing delicate, precise maneuvers that humans, with inherent physical abilities, may be limited to perform. The CorPath 200 system is FDA approved and is being implemented in the US for interventional cardiology procedures. CorPath GRX robotic-assisted platform is the next-generation successor of CorPath 200.

Objective

To discuss the feasibility and early experience with the use of the CorPath GRX robotic-assisted platform for neuroendovascular procedures, including transradial diagnostic cerebral angiograms and transradial carotid artery stenting.

Methods

The cases of 10 consecutive patients who underwent neuroendovascular robotic-assisted procedures between December 1, 2019 and December 30, 2019, are presented.

Results

Seven patients underwent elective diagnostic cerebral angiography, and three patients underwent carotid artery angioplasty and stenting using the CorPath GRX robotic-assisted platform. All procedures were performed successfully, and no complications were encountered. Conversion to manual control occurred in three diagnostic cases because of a bovine arch that was previously not known. The fluoroscopy time and the procedure time continued to improve with subsequent procedures as we streamlined the workflow.

Conclusion

This series demonstrates the early use of this technology. It could potentially be used in the near future for acute stroke interventions in remote geographic locations and in places where a neurointerventionalist is not available.

A novel noncontact detection method of surgeon's operation for a master-slave endovascular surgery robot

Master-slave endovascular interventional surgery (EIS) robots have brought revolutionary advantages to traditional EIS, such as avoiding X-ray radiation to the surgeon and improving surgical precision and safety. However, the master controllers of most of the current EIS robots always lead to bad human-machine interaction, because of the difference in nature between the rigid operating handle and the flexible medical catheter used in EIS. In this paper, a noncontact detection method is proposed, and a novel master controller is developed to realize real-time detection of surgeon's operation without interference to the surgeon. A medical catheter is used as the operating handle. It is enabled by using FAST corner detection algorithm and optical flow algorithm to track the corner points of the continuous markers on a designed sensing pipe. A mathematical model is established to calculate the axial and rotational motion of the sensing pipe according to the moving distance of the corner points in image coordinates. A master-slave EIS robot system is constructed by integrating the proposed master controller and a developed slave robot. Surgical task performance evaluation in an endovascular evaluator (EVE) is conducted, and the results indicate that the proposed detection method breaks through the axial measuring range limitation of the previous marker-based detection method. In addition, the rotational detection error is reduced by 92.5% compared with the previous laser-based detection method. The results also demonstrate the capability and efficiency of the proposed master controller to control the slave robot for surgical task implementation. Graphical abstract A novel master controller is developed to realize real-time noncontact detection of surgeon's operation without interference to the surgeon. The master controller is used to remotely control the slave robot to implement certain surgical tasks.