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  • Robotics in Neuroendovascular Surgery:
    The Future is Now

    Authors:
    Michael K Tso, MD,
    Gary B Rajah, MD and
    Rimal H Dossani, MD

    An endovascular robotic platform was first developed for interventional cardiac procedures. The first percutaneous coronary intervention (PCI) robotic system was the RNS (NaviCath, Haifa, Israel), which was a table-mounted, joystick-controlled apparatus.1. Subsequently, an initial robotic platform called the CorPath 2012 (Corindus Vascular Robotics, Waltham, MA, USA now recently acquired by Siemens Healthineers, Erlangen, Germany), was approved by the FDA in 2012 for PCI.1 This was followed by a next generation CorPath GRX (Corindus Vascular Robotics, Waltham, MA, USA), which was approved by the FDA in 2016 for PCI.1 The set-up involved a robotic arm mounted to the table with a disposable cassette and three slots used to place the guide catheter, rapid exchange catheter, and 014” microwire. The interventionalist, who sits at a workstation remote from the angio table, has the ability to advance and retract as well as rotate each of the three component slots. The CorPath GRX has also been successfully used in peripheral vascular interventions such as angioplasty for below-the-knee peripheral artery disease.2 In preclinical studies, the CorPath GRX was also used to navigate into intracranial arteries of animal models.3

    On November 1, 2019, a team at the Toronto Western Hospital in Toronto, Ontario, led by interventional neurosurgeon Dr. Vitor Pereira, performed the world’s first robotic intracranial neurovascular intervention. The patient was a 64-year-old female with a large unruptured left superior cerebellar artery (SCA) aneurysm undergoing elective stent-assisted coiling. Interventional neuroradiologists Dr. Timo Krings and Dr. Patrick Nicholson provided endovascular support at the bedside and Ms. Nicole Cancelliere, the radiation technologist, provided assistance with the CorPath robot itself. There were no intraprocedural complications and the patient was discharged the next day. The team at Toronto Western Hospital had acquired the robotic platform several months prior and trialed its use with a reconstructed flow model of the patient’s aneurysm. As of February 2020, the CorPath GRX has not yet been FDA approved for intracranial work. However, it has been used for diagnostic cerebral angiography and placement of extracranial stents. It is only a matter of time before the CorPath GRX will be approved for use in treating patients with intracranial vascular diseases in the US. The CorPath GRX platform has the potential to address several issues relevant to the endovascular treatment of patients with cerebrovascular diseases. With the neurointerventionalist in close proximity to the radiation source of the angio apparatus, there is still significant radiation exposure despite appropriate radiation hygiene (including lead apron, lead glasses, ceiling-mounted shield and floor shields, and possibly head shield). Repeated radiation exposure can result in stochastic (e.g. cancer) and deterministic effects (e.g. cataracts)4. By controlling the CorPath GRX from a remote shielded workstation, it possible to significantly reduce overall radiation exposure to the neurointerventionalist. Also, taking one step forward and using wireless technology, the interventionalist can be stationed in one location with the actual procedure being performed in a remote location, whether in another city or another state. This would help expand access to endovascular treatment for stroke to patients in remote areas and provide sufficient procedural case volume for neurointerventionalists to maintain expertise. There has been a trend toward decreasing case volume per hospital for mechanical thrombectomy, with better outcomes in high-volume hospitals.5 In addition, there is opportunity for provide education and mentoring at remote locations. Finally, the robotic platform has the potential to provide a greater degree of precision in neuroendovascular procedures, especially with placement of stents.

    The CorPath GRX platform was originally developed for PCI and is the first version to be used for intracranial pathology. There are significant limitations currently with this platform. There is still a considerable amount of work required for the angiography team at the patient’s bedside including obtaining arterial access, loading the catheters and wires, and deploying stents with a push-pull delivery system. There is a loss of tactile feedback when using the robotic platform. Wire and catheter exchanges can be cumbersome. Finally, there will be a learning curve with this new technology for not only the neurointerventionalist but for the entire neurointerventional team.

    Although we are still at the beginning of the early adoption phase of the innovation curve, robotics will have an increasing role in neuroendovascular procedures. The future is now.

     

     References

    1. Walters D, et al. Robotic-assisted percutaneous coronary intervention. Intervent Cardiol Clin. 2019;8:149-159.

    2. Behnamfar O, et al. First case of robotic percutaneous vascular intervention for below-the-knee peripheral artery disease. J Invasive Cardiol. 2016;28(11):E128-E131.

    3. Britz GW, et al. Feasibility of robotic-assisted neurovascular intervention: Initial experience in flow model and porcine model. Neurosurgery. 2020;86(2):309-314.

    4. Andreassi MG, et al. Occupational health risks in cardiac catheterization laboratory workers. Circ Cardiovasc Interv. 2016;9:e003273.

    5. Saber H, et al. Real-world treatment trends in endovascular stroke therapy. Stroke. 2019;50:683-689.

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