Robotic coronary angioplasty

Robotic coronary angioplasty

Percutaneous coronary interventions are the state of the art in the management of coronary artery disease, especially in the case of acute coronary syndromes. In ST elevation myocardial infarction, early PCI is the standard of care, while in many non ST elevation acute coronary syndromes PCI plays an all important role in management. In spite of this PCI is a high occupational risk procedure for the performing medical team, with significant radiation exposure and possibility of orthopedic problems due to the heavy lead aprons. In order to overcome these problems, robotic angioplasty was developed, in which physician can work with precision from the comfort of a radiation protected console.

Potential benefits for the patient might include lesser radiation exposure, lesser contrast delivery and shorter procedure times due to more accurate navigation by the robotic system. Precise stent placements have a potential for better outcome and possibly lesser cost by avoiding extra stents in situations of foreshortening. Accurate lesion measurements using the automated system helps in precise sizing of the stents.

First in human robotic coronary angioplasty study documented a technical success of 97.9% with robotic system completing 47 of the 48 planned steps. Device clinical success of less than 30% luminal stenosis was obtained in all the 8 patients enrolled in the study.¹ There were no device or procedure related complications in this small study and there were no major adverse cardiac events in hospital or at 30 days. Radiation exposure to the operator was 97% less than at conventional operating position at the cath table.

A further safety and feasibility study on robotic angioplasty was published in JACC in 2013.² Technical success was obtained in 162 of the 164 patients enrolled at 9 sites. Clinical success was demonstrated in 160 patients and periprocedural non Q wave myocardial infarction occurred in 4 patients, though there were no device related complications. Radiation exposure was 95.2% less for the operator compared to usual operator location for PCI. None of the patients died or had Q wave infarction at 30 days and neither did they need revascularization during this period.

Robotic coronary angioplasty system

The robotic angioplasty system has two important components: the interventional cockpit and a bedside unit. The interventional cockpit is a mobile workstation located at a corner of the cardiac catheterization laboratory. It has radiation shielding and remote PCI is performed by the interventional cardiologist using joysticks or touch screen commands. A sterile cassette is placed on the robotic drive which is electrically connected to the control console by a communication cable. The cassette is loaded with guide wires and balloons connected to the guide catheter.

Commercially available guidewires and stent delivery systems can be used with the cassette. Guide catheter is connected to the robotic system disposable cassette after a conventional diagnostic angiography and guide engaging of coronary ostium. Bail out to manual conversion is done when needed. All procedures were performed by femoral access. Conversion to manual procedure was needed due to severe resistance to stent delivery in 2 cases, which were also difficult manually, needing advanced interventional techniques.

Systematic review and meta analysis December 2022

A systematic review and meta analysis compared manual PCI with robotic PCI and was published in December 2022. They included 20 studies for qualitative analysis and 7 studies for pooled meta analysis. There was no significant difference between the two groups in terms of clinical success and procedure time. Contrast volume and fluoroscopy time were lower in the robotic PCI group. Technical success  in all studies were 70% or more with four studies reporting 100% success rates [3].

References

1. Granada JF et al. First-in-human evaluation of a novel robotic-assisted coronary angioplasty system. JACC Cardiovasc Interv. 2011;4:460-5.
2. Weisz G et al. Safety and feasibility of robotic percutaneous coronary intervention: PRECISE (Percutaneous Robotically-Enhanced Coronary Intervention) Study. J Am Coll Cardiol. 2013;61:1596-600.
3. Jaffar-Karballai M, Haque A, Voller C, Elleithy A, Harky A. Clinical and technical outcomes of robotic versus manual percutaneous coronary intervention: A systematic review and meta-analysis. J Cardiol. 2022 Dec;80(6):495-504. doi: 10.1016/j.jjcc.2022.02.002. Epub 2022 Feb 12. PMID: 35165012.