Evaluation of Robotic-Assisted Carotid Artery Stenting in a Virtual Model Using Motion-Based Performance Metrics

Abstract

Purpose:

Robotic-assisted carotid artery stenting (CAS) cases have been demonstrated with promising results. However, no quantitative measurements have been made to compare manual with robotic-assisted CAS. This study aims to quantify surgical performance using tool tip kinematic data and metrics of precision during CAS with manual and robotic control in an ex vivo model.

Materials and Methods:

Transfemoral CAS cases were performed in a high-fidelity endovascular simulator. Participants completed cases with manual and robotic techniques in 2 different carotid anatomies in random order. C-arm angulations, table position, and endovascular devices were standardized. Endovascular tool tip kinematic data were extracted. We calculated the spectral arc length (SPARC), average velocity, and idle time during navigation in the common carotid artery and lesion crossing. Procedural time, fluoroscopy time, movements of the deployed filter wire, precision of stent, and balloon positioning were recorded. Data were analyzed and compared between the 2 modalities.

Results:

Ten participants performed 40 CAS cases with a procedural success of 100% and 0% residual stenosis. The median procedural time was significantly higher during the robotic-assisted cases (seconds, median [interquartile range, IQR]: 128 [49.5] and 161.5 [62.5], p=0.02). Fluoroscopy time differed significantly between manual and robotic-assisted procedures (seconds, median [IQR]: 81.5 [32] and 98.5 [39.5], p=0.1). Movement of the deployed filter wire did not show significant difference between manual and robotic interventions (mm, median [IQR]: 13 [10.5] and 12.5 [11], p=0.5). The postdilation balloon exceeded the margin of the stent with a median of 2 [1] mm in both groups. Navigation with robotic assistance showed significantly lower SPARC values (–5.78±3.14 and –8.63±3.98, p=0.04) and higher idle time values (8.92±8.71 and 3.47±3.9, p=0.02) than those performed manually.

Conclusions:

Robotic-assisted and manual CAS cases are comparable in the precision of stent and balloon positioning. Navigation in the carotid artery is associated with smoother motion and higher idle time values. These findings highlight the accuracy and the motion stabilizing capability of the endovascular robotic system.

Clinical Impact

Robotic assistance in the treatment of peripheral vascular disease is an emerging field and may be a tool for radiation protection and the geographic distribution of endovascular interventions in the future. This preclinical study compares the characteristics of manual and robotic-assisted carotid stenting (CAS). Our results highlight, that robotic-assisted CAS is associated with precise navigation and device positioning, and smoother navigation compared to manual CAS.

Keywords

carotid stent/stenting robotic-assisted surgery motion analysis endovascular treatment/therapy peripheral vascular disease performance metrics

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References

Panesar

Volpi

Lumsden

, et al. Telerobotic stroke intervention: a novel solution to the care dissemination dilemma. J Neurosurg. 2020;132(3):971–978.

Weisz

Metzger

Caputo

, et al. Safety and feasibility of robotic percutaneous coronary intervention: PRECISE (percutaneous robotically-enhanced coronary intervention) study. J Am Coll Cardiol. 2013;61(15):1596–1600.

Patel

Shah

Pancholy

SB.

Long distance tele-robotic-assisted percutaneous coronary intervention: a report of first-in-human experience. EClinicalMedicine. 2019;14:53–58.

George

Tabaza

Janzer

Robotic-assisted balloon angioplasty and stent placement with distal embolic protection device for severe carotid artery stenosis in a high-risk surgical patient. Catheter Cardiovasc Interv. 2020;96(2):410–412.

Nogueira

Sachdeva

Al-Bayati

, et al. Robotic assisted carotid artery stenting for the treatment of symptomatic carotid disease: technical feasibility and preliminary results. J Neurointerv Surg. 2020;12(4):341–344.

Sajja

Sweid

Al Saiegh

, et al. Endovascular robotic: feasibility and proof of principle for diagnostic cerebral angiography and carotid artery stenting. J Neurointerv Surg. 2020;12(4):345–349.

Weinberg

Sweid

Sajja

, et al. Comparison of robotic-assisted carotid stenting and manual carotid stenting through the transradial approach. J Neurosurg. 2020;135(1):21–28.

Madder

VanOosterhout

Mulder

, et al. Network latency and long-distance robotic telestenting: exploring the potential impact of network delays on telestenting performance. Catheter Cardiovasc Interv. 2020;95(5):914–919.

Britz

Tomas

Lumsden

Feasibility of robotic-assisted neurovascular interventions: initial experience in flow model and porcine model. Neurosurgery. 2020;86(2):309–314.

10.

Lettenberger

Murali

Legeza

, et al. Comparing manual and robotic-assisted carotid artery stenting using motion-based performance metrics. In: Proceedings of the IEEE Engineering in Medicine and Biology Conference (EMBC). 2021. doi:10.1109/EMBC46164.2021.9630895.

11.

Estrada

Duran

Schulz

, et al. Smoothness of surgical tool tip motion correlates to skill in endovascular tasks. IEEE Trans Human-Machine Syst. 2016;46(5):647–659.

12.

O’Malley

Byrne

Estrada

, et al. Expert surgeons can smoothly control robotic tools with a discrete control interface. IEEE Trans Human-Machine Syst. 2019;49(4):388–394.

13.

Balasubramanian

Melendez-Calderon

Roby-Brami

, et al. On the analysis of movement smoothness. J Neuroeng Rehabil. 2015;12(1):1–11.

14.

Murali

Belvroy

Pandey

, et al. Towards automated performance assessment using velocity-based motion quality metrics. In: 2020 International Symposium on Medical Robotics (ISMR). 2020:36–42. doi:10.1109/ISMR48331.2020.9312946.

15.

Mahmud

Schmid

Kalmar

, et al. Feasibility and safety of robotic peripheral vascular interventions: results of the RAPID trial. JACC Cardiovasc Interv. 2016;9(19):2058–2064.

16.

Brott

Halperin

Abbara

, et al. 2011 ASA/ACCF/AHA/AANN/AANS/ACR/ASNR/CNS/SAIP/SCAI/SIR/SNIS/SVM/SVS guideline on the management of patients with extracranial carotid and vertebral artery disease. A report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American Stroke Association, American Association of Neuroscience Nurses, American Association of Neurological Surgeons, American College of Radiology, American Society of Neuroradiology, Congress of Neurological Surgeons, Society of Atherosclerosis Imaging and Prevention, Society for Cardiovascular Angiography and Interventions, Society of Interventional Radiology, Society of Neurointerventional Surgery, Society for Vascular Medicine, and Society for Vascular Surgery. Circulation. 2011;124:e54–e130.

17.

Naylor

Ricco

de Borst

, et al. Editor’s choice—management of atherosclerotic carotid and vertebral artery disease: 2017 clinical practice guidelines of the European Society for Vascular Surgery (ESVS). Eur J Vasc Endovasc Surg. 2018;55(1):3–81.

18.

Cole

Mezher

Catapano

, et al. Nationwide trends in carotid endarterectomy and carotid artery stenting in the post-CREST era. Stroke. 2020;51:579–587.

19.

Brott

Hobson

II Howard

, et al. Stenting versus endarterectomy for treatment of carotid-artery stenosis. N Engl J Med. 2010;363(1):11–23.

20.

Garami

Bismuth

Charlton-Ouw

, et al. Feasibility of simultaneous pre- and postfilter transcranial Doppler monitoring during carotid artery stenting. J Vasc Surg. 2009;49(2):340–345.

21.

Plessers

Van Herzeele

Hemelsoet

, et al. Transcervical carotid stenting with dynamic flow reversal demonstrates embolization rates comparable to carotid endarterectomy. J Endovasc Ther. 2016;23(2):249–254.

22.

Montorsi

Caputi

Galli

, et al. Microembolization during carotid artery stenting in patients with high-risk, lipid-rich plaque. A randomized trial of proximal versus distal cerebral protection. J Am Coll Cardiol. 2011;58(16):1656–1663.

23.

Kim

Lee

Yang

, et al. The influence of carotid artery catheterization technique on the incidence of thromboembolism during carotid artery stenting. AJNR Am J Neuroradiol. 2010;31(9):1732–1736.

24.

Wooster

Doyle

Hislop

, et al. REHEARSAL using patient-specific simulation to improve endovascular efficiency. Vasc Endovascular Surg. 2018;52(3):169–172.

25.

Dayal

Faries

Lin

, et al. Computer simulation as a component of catheter-based training. J Vasc Surg. 2004;40(6):1112–1117.

26.

Coates

Zealley

Chakraverty

Endovascular simulator is of benefit in the acquisition of basic skills by novice operators. J Vasc Interv Radiol. 2010;21(1):130–134.

27.

Rolls

Riga

Rahim

, et al. The use of video motion analysis to determine the impact of anatomic complexity on endovascular performance in carotid artery stenting. J Vasc Surg. 2019;69(5):1482–1489.

28.

Rolls

Riga

Bicknell

, et al. A pilot study of video-motion analysis in endovascular surgery: development of real-time discriminatory skill metrics. Eur J Vasc Endovasc Surg. 2013;45(5):509–515.

29.

Legeza

Britz

Loh

, et al. Current utilization and future directions of robotic-assisted endovascular surgery. Expert Rev Med Devices. 2020;17(9):919–927. doi:10.1080/17434440.2020.1814742.