Neuroendovascular-specific engineering modifications to the CorPath GRX Robotic System

Gavin W. Britz Department of Neurological Surgery and Neurological Institute, and

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 MD, MBA, MPH
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Sandip S. Panesar Department of Neurological Surgery and Neurological Institute, and

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 MD, MSc
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Peter Falb Corindus, Inc., Waltham, Massachusetts

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Johnny Tomas Corindus, Inc., Waltham, Massachusetts

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Virendra Desai Department of Neurological Surgery and Neurological Institute, and

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Alan Lumsden Department of Cardiovascular Surgery, Houston Methodist Hospital, Texas Medical Center, Houston, Texas; and

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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.

ABBREVIATIONS

ADF = active device fixation; AI = artificial intelligence; CCA = common carotid artery; ICA = internal carotid artery; PCI = percutaneous coronary intervention; PVI = peripheral vascular intervention.

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.

In Brief

The authors predict that robots will play an important role in the field of endovascular neurosurgery in the future. Research to date has been done on robotic devices that were developed for cardiovascular and peripheral vascular applications. In the process of developing a neurovascular-specific robot, new, neuroendovascular-specific engineering and software modifications to the CorPath GRX Robotic System have to be made to allow for safer and more effective intracranial neurovascular interventions. This article demonstrates this work.

The advent of catheter-based percutaneous techniques for endovascular intervention within the brain, including coiling of intracranial aneurysms, embolization of arteriovenous malformations, and thrombectomy for strokes, promises to greatly enhance outcomes and patient safety in the field of neurosurgery.5,21,27,28 A logical next advance will be to harness the power and benefits of robot-assisted surgical and endovascular techniques, which have already been explored in general surgery, cardiothoracic surgery, and neurosurgery, as well as in cardiovascular and peripheral vascular interventions. Robot-assisted platforms have enabled minimally invasive spine, cardiac, and prostate surgery.5,8,13,14,18,20 They have also been used for percutaneous coronary intervention (PCI) and peripheral vascular intervention (PVI).2,3,15–17,23,24,26 Notable benefits of robotic techniques include reduced orthopedic strain and radiation exposure to the surgeon and staff, among a host of others.25 Although several robot-assisted platforms have been approved for selected neurosurgical procedures,7–9,19 these systems were not specifically designed for the small instruments and the precise, minute movements required for cerebral endovascular applications.

Recently, we evaluated the feasibility of using the current iteration of the CorPath GRX Vascular Robotic System (Corindus, Inc.) as a robotic platform for intracranial neurovascular interventions.4 While the results were, in our view, highly promising, a principal limitation of the robotic platform was that it was designed with percutaneous cardiovascular and peripheral vascular, rather than neurovascular, applications in mind. The cassette and arm were not, at the time of the study, able to reliably manage the relevant microcatheters and microscale guidewires without occasional herniation of the devices from the drive tracks. Additionally, of great concern for intracranial navigation is the fear of perforation. Navigation within the smaller scale of the intracranial vasculature was challenging because the navigational control software and the movements it produced were designed for the vessels involved in PCI and PVI techniques. This resulted in inadvertent forward movement of the wire when delivering the microcatheter, which could potentially result in perforation in the neurovascular tree.

In response to the findings of the initial study, research and development personnel at the manufacturer developed several engineering and software modifications to address these limitations. In this report, we describe a new feasibility evaluation carried out in a porcine model to determine whether these changes have improved the potential utility and safety of the platform, with an eye toward assessing its suitability for use in clinical neurovascular applications.

Methods

Robotic System

The robotic navigation system under evaluation is a modification of the CorPath GRX Robotic System (Corindus, Inc.), which has been described previously.4,10,16,29 It is currently cleared by the FDA for PCI and PVI but not yet for neurovascular intervention, and the modifications being tested here have not yet been cleared for any use. Therefore, the preclinical experiments in this report represent an off-label use of the system for investigational purposes. Users should consult the operator’s manual for intended use and compatible device information prior to performing any case with the CorPath GRX System.

The robotic system has 2 principal components. One is the remote workstation, which houses the navigational control software and provides a comfortable, remote, mobile, and radiation-shielded user interface with a touchscreen control console, 3 joysticks for remote, robot-assisted manipulation of the interventional devices, and an ultra–high-definition display monitor. The monitor simultaneously displays as many as 8 high-definition images from different sources, including live- and reference-image fluoroscopy and patient hemodynamics, as well as fractional flow reserve, intravascular ultrasound, and other adjunct technologies.

The other component is the tableside unit, which is connected to the workstation by a communication cable. The function of the unit’s articulating robotic arm is to position the robotic drive system and the sterile, single-use cassette appropriately to enable patient access during the procedure. The workstation interface, software, robotic drive motors, and cassette work together to translate the interventionalist’s directions into precise and controlled linear, rotational, and pinch micromovements in the guide or microcatheter, guidewire, and rapid-exchange balloons, stents, coils, or other working devices during navigation and intervention.

Software and Engineering Modifications

The standard software for the robotic system is designed such that, when the microcatheter is advanced or retracted, the guidewire and working device move in an equivalent direction (forward or backward) and distance (Fig. 1A). While this movement can be compensated for by manipulation of the joysticks by the operator, we were concerned that unexpected or counterintuitive motion of the catheter-device-guidewire assembly could potentially increase the risk of perforating delicate neurovascular structures during navigation. Therefore, we determined that neurovascular interventions required a feature that would automate independent manipulation of the guidewire and device relative to the microcatheter. In response to this user requirement, the company developed an optional software feature called active device fixation (ADF). When ADF is enabled, the microcatheter can be advanced and retracted through automated software without changing the positions of the guidewire and working device relative to patient anatomy (Fig. 1B). Prior to the animal procedure, a software upgrade was performed by loading the prototype software (version 1.2.0 was used in this study) onto the workstation.

FIG. 1.
FIG. 1.

Schematic showing device movement without (A) and with (B) ADF software enabled. A: When the operator manipulates the microcatheter (orange) under control of the robotic drive, the guidewire (green) and working device (purple) may also move in response to movements of the robotic system. Thus, without the ADF software, the operator must compensate for unexpected movements in the guidewire with counteracting movements of the respective joystick. B: The ADF software uses open-loop control of the guidewire and working device to automatically counteract unexpected movements that occur in response to microcatheter actuation. The software generates this counteracting movement by approximating the movement of the microcatheter as directed by the guide catheter joystick’s command, and then simultaneously and automatically commands an equal and opposite movement in the guidewire and working device. Thus, even as the microcatheter retracts, the guidewire and working device remain in position relative to the patient’s anatomy. The guidewire and working device joysticks can still be maneuvered independently during an ADF movement, and their commands are simply added to the ADF command.

The second user requirement to be addressed for neurovascular intervention was physical modification of the single-use cassette to securely and reliably accommodate the smaller-gauge devices common to percutaneous neurosurgery. The original cassette was intended for use with catheters specifically sized for cardiovascular and peripheral vascular intervention. In the previous neurovascular feasibility study, we found that the microcatheters occasionally “looped out,” or herniated, from the guide track in the cassette. We also found that some of the smaller-diameter devices, such as coils, were too short in length to use in the cassette’s guidewire track, which is essential for the system to properly monitor their actual movements. In response to this feedback, the manufacturer developed 3 modifications. The first is a new Y-connector cover with a protuberance designed to constrain the devices and prevent them from herniating out of the cassette near the drive gear (Fig. 2A). The second is the use of a new Y-connector adapter, composed of a separate piece that attaches to a hemostatic valve adaptor and a microcatheter clip that attaches to the track and connects to the Y-connector adapter (Fig. 2B). The third modification was to change the drive gearing inside the cassette to make it compatible with smaller-diameter devices such as coils and stents, in order to facilitate tracking of the actual device motion separate from the drive motors.

FIG. 2.
FIG. 2.

Engineering modifications to the robotic single-use cassette. A: A new Y-connector cover (arrowhead) prevents small-gauge devices from herniating out of the cassette during manipulation. B: A new Y-connector adapter attaches to a hemostatic valve adaptor (arrowhead), and a microcatheter clip that attaches to the track and connects to the Y-connector adapter. C: The robotic cassette and catheters in place for the procedure.

Devices

Navigational and interventional devices used for these experiments were a Synchro2 0.014-inch × 200-cm hydrophilic guidewire (Stryker Neurovascular); and a 45° tip shape, 1.7-F/2.1-F inner/outer diameter, 150-cm microcatheter (Echelon 10, Medtronic Inc.).

Porcine Model

The animal procedure was conducted at the Houston Methodist Institute for Technology, Innovation & Education in accordance with US and international regulations for the protection of laboratory animals and following a protocol approved by the institution’s Animal Care and Use Committee. We chose to use the cervical carotid lesions, since in the porcine model, extracranial vessel sizes are similar to those in human intracranial vessels. Therefore, the same-sized catheters and wires will be used in humans in the future. As modifications are made to the robotic system, including the cassettes, these changes can be directly incorporated into future use in humans.

No more than 0.5 hours prior to the start of the device evaluation procedure, a female domestic swine (42 kg) was administered standard general anesthesia and underwent sterile surgical preparation. An aneurysm was surgically induced in the left proximal common carotid artery (CCA) as previously described.6 Briefly, after an elliptical arteriotomy, a distal stump of the ipsilateral internal jugular vein was anastomosed to the left CCA to create an aneurysm.

Preparation for the robot-assisted interventional procedure began with manual, nonrobotic introduction of a sheath (Neuron MAX 088 6F, Penumbra Inc.) with a 0.035/0.038-inch guidewire to access the femoral artery. The guidewire and sheath were navigated manually, under fluoroscopic guidance, up to the aortic arch and manually introduced into the common carotid artery under fluoroscopic guidance.

Once the guide sheath was correctly located, the diagnostic catheter and guidewire were removed, and the sheath’s hub was attached to a Copilot Bleedback Control Valve (Abbott Vascular) with the Tuohy-Borst valve in the open position.

An angiogram was obtained to confirm the location and size of the induced aneurysm. Once the angiography study was complete, the 0.014-inch × 200-cm hydrophilic guidewire and 1.7-F/2.1-F, 150-cm microcatheter were assembled and advanced manually to the tip of the sheath. The proximal ends were loaded into the corresponding tracks of the robot system’s modified single-use cassette (Fig. 2C) and secured, and the operator was seated at the workstation.

Procedures included navigation to and from 2 extracranial sites (the rete mirabile and the site of the aneurysm) with and without ADF. For each procedure, when the ADF was inactive, the operator relied on using the joysticks to retract the guidewire or working device to counteract advancements of the microcatheter as needed. With ADF activated, the operator observed the ability of the system to automate these counteracting movements. Success was defined as the ability to perform each procedure as planned. Once all procedures had been completed, all devices were removed, and the access site was closed. The animal was then humanely euthanized.

Results

On angiography, the aneurysm measured 12.3 × 12.9 mm. Following surgical preparation, angiography, and robotic system setup, the guidewire and microcatheter were successfully navigated under robotic assistance to the first target, the rete mirabile, both with the ADF software feature inactive (Fig. 3 and Video 1) and activated (Fig. 4 and Video 2).

VIDEO 1. Advancement of guidewire and microcatheter into rete mirabile, without ADF activated. Copyright Gavin W. Britz. Published with permission. Click here to view.

VIDEO 2. Advancement of guidewire and microcatheter into rete mirabile, with ADF activated. Copyright Gavin W. Britz. Published with permission. Click here to view.

FIG. 3.
FIG. 3.

Navigation without ADF enabled. A: The guidewire is placed into the induced aneurysm robotically with the microcatheter that was advanced robotically but left in the CCA. B: The operator manipulates the microcatheter, under control of the robotic drive, over the guidewire into the aneurysm without the ADF software feature enabled. Despite the operator’s use of counteracting movements of the respective joystick to compensate for unexpected movements in the microwire, the microwire can be seen advancing unsafely beyond the end of the microcatheter.

FIG. 4.
FIG. 4.

Navigation with the ADF enabled. A: The guidewire is placed in the induced aneurysm robotically with the microcatheter that was advanced robotically but left in the CCA. B: The operator manipulates the microcatheter, under control of the robotic drive, over the guidewire into the aneurysm with the ADF software feature enabled. During manipulation, the guidewire can be seen to stay within the end of microcatheter.

As in standard nonrobotic procedures, it was necessary to shape the guidewire tip to achieve smooth and successful navigation. Compared with the condition in which ADF was inactive (compare Videos 1 and 2), manipulating the microcatheter with the ADF function activated resulted in smoother navigation without unexpected forward motion of the guidewire (Table 1).

TABLE 1.

Guidewire movement during advancement of the microcatheter in two anatomical locations with and without the ADF software feature

Guidewire Movement (mm)
Anatomical Location & Attempt No.ADF StatusForwardBackward
ICA toward the rete mirabile
 1Inactive60
 2Inactive40
 3Active02
 4Active01
CCA toward the aneurysm
 1Inactive60
 2Inactive40
 3Active02
 4Active01

Data are descriptive only. Due to the small sample size, no statistical analysis or testing were performed.

Next, the guidewire and microcatheter were successfully navigated under robotic assistance to the second target, the induced aneurysm, both with the ADF software feature inactive (Video 1) and activated (Video 2). Navigating the guidewire and microcatheter to the aneurysm was successful in 3 of 3 attempts under operator control with and without ADF. Without ADF, the operator had to extensively employ the “push-pull” technique to keep the guidewire from perforating the wall of the aneurysm when advancing the microcatheter (Video 3).

VIDEO 3. Advancement of guidewire and microcatheter into aneurysm, without ADF activated. Copyright Gavin W. Britz. Published with permission. Click here to view.

In contrast, with ADF active, the push-pull technique was not necessary. Instead, the microcatheter could be advanced along the guidewire without the wire moving forward into the aneurysm (Table 1; Videos 4 and 5).

VIDEO 4. Advancement of guidewire and microcatheter into aneurysm, with ADF activated, trial A. Copyright Gavin W. Britz. Published with permission. Click here to view.

VIDEO 5. Advancement of guidewire and microcatheter into aneurysm, with ADF activated, trial B. Copyright Gavin W. Britz. Published with permission. Click here to view.

Similar findings were observed when navigating toward the rete mirabile

During this series of experiments, there were no occurrences of dissection, extravasation, or thrombosis in either the CCA (the location of the aneurysm) or the internal carotid artery (ICA; the vessel most proximal to the rete mirabile). Furthermore, there were no instances in which any of the microcatheters used in this experiment herniated from the cassette’s guide track while in use.

Discussion

The purpose of this study was to evaluate whether the described engineering and software modifications improved the ease and confidence with which an operator could manipulate navigational and interventional devices within the cranial neurovasculature.

We found that the ADF feature and the modifications to the cassette facilitated use of the small devices sized for neurovascular-specific interventions. All devices remained in their appropriate guide tracks during use, and the ADF modification automated the independent manipulation of the microcatheter, guidewire, and interventional devices in a way that provided additional confidence and control.

The ADF feature was successful in all attempts. It is important to consider that the operator in this case (G.W.B.) has extensive experience with the system without the ADF feature, through laboratory use as well as with manual neurovascular intervention in the clinical setting. Therefore, it is not surprising that the ADF-inactive trials were successful because the operator was used to manually overcompensating for the movement of the guidewire when the microcatheter is manipulated. The purpose of ADF is to reduce unexpected movements of the guidewire by the robotic system when the microcatheter is manipulated, but the operator must still perform counteracting movements on the guidewire when manipulating the microcatheter. Navigation with the ADF feature enabled improved with experience.

One design limitation we encountered was a hardware constraint that required a workaround for these experiments. The “working length” refers to the total distance the robot is able to drive microcatheters and guide catheters forward during navigation. The current iteration of the CorPath GRX robot was specifically designed for cardiovascular intervention (e.g., to reseat a guide catheter in the aortic arteries), requiring a much shorter working length than that required for neurovascular catheters. Therefore, the maximum total working length of the robot used here was 200 mm where the current GRX system centers the system in the middle of the 200-mm stroke to enable reseating the guide catheter. To mitigate the issue for this study, we created a temporary workflow within the software to bias the home position of the robot to provide for more forward motion of the microcatheter. This hardware limitation was noted, and it was recommended that the center home position be changed during the neurovascular-specific product development to a position that biases the home position to maximize the forward motion of the microcatheter.

The ADF software counteracts the additional movement of the devices when the microcatheter is robotically manipulated, and thereby enables the operator to compensate for the natural movement of the microcatheter in the same way that they are used to with manual procedures.

Iatrogenic perforation of intracranial vessels is a known complication of neuroendovascular intervention and can have devastating consequences, including subarachnoid hemorrhage that can result in permanent neurological deficit or death.11,12 In the setting of stroke treatment, the incidence of perforation has been estimated to occur at a rate of 1%–9%.1 Thus, any robotic or otherwise automated navigational technology designed to facilitate neurovascular intervention must include, in its design, mechanisms to reduce the occurrence of unexpected or poorly controlled guidewire movements. There will be continual advancement in endovascular robots in multiple fronts. Currently, robotics systems are only relying on mechanical movements. At present, no innate or autonomous “intelligence” is involved. In the future, this will change, and artificial intelligence (AI) learning will be added, which will enhance the safety and efficacy of robotics. AI learning with improved understanding of the movements with repeat experiences may create and allow for safer but more effective navigation. Reliably trained algorithms may be able to detect instrument encroachment on critical vascular structures and prevent their further advancement. These would be substantial improvements, and, if combined with AI and learning with image guidance, an even better product will be produced.22

We previously evaluated the CorPath GRX System in a porcine model because we were interested in the potential for improved outcomes. We found that it had potential for use in neurovascular indications; however, undesirable and unexpected forward movements of the guidewire did occur when advancing the microcatheter.4 Because patient safety is the priority, such undesirable actions would significantly decrease the utility of the robot for neurovascular interventions. We have shown that the modifications described here counteract the unfavorable movements in a porcine model, making navigation smoother and more intuitive, which could potentially improve the safety of robot-assisted interventions for all endovascular applications, and potentially enable more complex intervention in the PCI and PVI settings.

This study is limited in that it was a small, preclinical pilot investigation. We used software based on preliminary models and hardware that was not yet optimized for neurovascular intervention. Moreover, although the ultimate goal is to eventually utilize the endovascular robot on human intracranial neurovasculature, its efficacy and safety must be reliably proved. We chose to use the cervical carotid lesions since extracranial vessels in pigs are similar in size to human intracranial vessels. Therefore, the same catheters and wires used in this study will be used in humans in the future. As modifications are made to the robotic system, including the cassettes, these changes can be directly incorporated for future use in humans. However, based on our experience and observations, we believe that ADF and the engineering modifications to the hardware have improved the reliability, consistency, ease of use, and potential safety of the system for both extracranial and intracranial applications. Based on our findings, Corindus has made additional improvements to the ADF software and has subsequently requested 510(k) premarket clearance for software version 2.0, for inclusion in the CorPath GRX Vascular Robotic System.

Conclusions

Active device fixation and other recent engineering modifications to the CorPath GRX Vascular Robotic System have improved the system’s utility and potential safety in neurovascular and other endovascular interventions. With the new modifications described, clinical access of the robotic system for this indication is warranted.

Acknowledgments

Jeanne McAdara, PhD (Biolexica LLC, Longmont, CO), provided professional assistance with manuscript preparation, which was funded by Corindus, Inc.

Disclosures

Mr. Falb and Mr. Tomas: employed by Corindus. Dr. Desai: direct stock ownership in Corindus Vascular Robotics. Dr. Lumsden: consultant for and direct stock ownership in Corindus.

Author Contributions

Conception and design: Britz, Lumsden. Acquisition of data: Britz, Panesar, Falb, Tomas, Desai. Analysis and interpretation of data: Britz, Falb, Tomas, Desai, Lumsden. Drafting the article: Britz. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Britz. Study supervision: Britz.

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    Smilowitz NR, Moses JW, Sosa FA, Lerman B, Qureshi Y, Dalton KE, et al.: Robotic-enhanced PCI compared to the traditional manual approach. J Invasive Cardiol 26:318321, 2014

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    • Export Citation
  • 25

    Smilowitz NR, Weisz G: Robotic-assisted angioplasty: current status and future possibilities. Curr Cardiol Rep 14:642646, 2012

  • 26

    Smitson CC, Ang L, Pourdjabbar A, Reeves R, Patel M, Mahmud E: Safety and feasibility of a novel, second-generation robotic-assisted system for percutaneous coronary intervention: first-in-human report. J Invasive Cardiol 30:152156, 2018

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Solomon RA, Connolly ES Jr: Arteriovenous malformations of the brain. N Engl J Med 376:18591866, 2017

  • 28

    Starke RM, Turk A, Ding D, Crowley RW, Liu KC, Chalouhi N, et al.: Technology developments in endovascular treatment of intracranial aneurysms. J Neurointerv Surg 8:135144, 2016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Weisz G, Metzger DC, Caputo RP, Delgado JA, Marshall JJ, Vetrovec GW, et al.: Safety and feasibility of robotic percutaneous coronary intervention: PRECISE (Percutaneous Robotically-Enhanced Coronary Intervention) Study. J Am Coll Cardiol 61:15961600, 2013

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The Neurosurgery Research & Education Foundation (NREF) is celebrating its 40th anniversary this month. Since its inception, the NREF has invested nearly $30 million in the future of neurosurgery through its support of basic science and clinical research, as well as life-long education, to foster improved outcomes for our patients with neurosurgical diseases. See the article by Agarwal et al. (pp 1905–1912).

  • FIG. 1.

    Schematic showing device movement without (A) and with (B) ADF software enabled. A: When the operator manipulates the microcatheter (orange) under control of the robotic drive, the guidewire (green) and working device (purple) may also move in response to movements of the robotic system. Thus, without the ADF software, the operator must compensate for unexpected movements in the guidewire with counteracting movements of the respective joystick. B: The ADF software uses open-loop control of the guidewire and working device to automatically counteract unexpected movements that occur in response to microcatheter actuation. The software generates this counteracting movement by approximating the movement of the microcatheter as directed by the guide catheter joystick’s command, and then simultaneously and automatically commands an equal and opposite movement in the guidewire and working device. Thus, even as the microcatheter retracts, the guidewire and working device remain in position relative to the patient’s anatomy. The guidewire and working device joysticks can still be maneuvered independently during an ADF movement, and their commands are simply added to the ADF command.

  • FIG. 2.

    Engineering modifications to the robotic single-use cassette. A: A new Y-connector cover (arrowhead) prevents small-gauge devices from herniating out of the cassette during manipulation. B: A new Y-connector adapter attaches to a hemostatic valve adaptor (arrowhead), and a microcatheter clip that attaches to the track and connects to the Y-connector adapter. C: The robotic cassette and catheters in place for the procedure.

  • FIG. 3.

    Navigation without ADF enabled. A: The guidewire is placed into the induced aneurysm robotically with the microcatheter that was advanced robotically but left in the CCA. B: The operator manipulates the microcatheter, under control of the robotic drive, over the guidewire into the aneurysm without the ADF software feature enabled. Despite the operator’s use of counteracting movements of the respective joystick to compensate for unexpected movements in the microwire, the microwire can be seen advancing unsafely beyond the end of the microcatheter.

  • FIG. 4.

    Navigation with the ADF enabled. A: The guidewire is placed in the induced aneurysm robotically with the microcatheter that was advanced robotically but left in the CCA. B: The operator manipulates the microcatheter, under control of the robotic drive, over the guidewire into the aneurysm with the ADF software feature enabled. During manipulation, the guidewire can be seen to stay within the end of microcatheter.

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  • 23

    Smilowitz NR, Balter S, Weisz G: Occupational hazards of interventional cardiology. Cardiovasc Revasc Med 14:223228, 2013

  • 24

    Smilowitz NR, Moses JW, Sosa FA, Lerman B, Qureshi Y, Dalton KE, et al.: Robotic-enhanced PCI compared to the traditional manual approach. J Invasive Cardiol 26:318321, 2014

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Smilowitz NR, Weisz G: Robotic-assisted angioplasty: current status and future possibilities. Curr Cardiol Rep 14:642646, 2012

  • 26

    Smitson CC, Ang L, Pourdjabbar A, Reeves R, Patel M, Mahmud E: Safety and feasibility of a novel, second-generation robotic-assisted system for percutaneous coronary intervention: first-in-human report. J Invasive Cardiol 30:152156, 2018

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Solomon RA, Connolly ES Jr: Arteriovenous malformations of the brain. N Engl J Med 376:18591866, 2017

  • 28

    Starke RM, Turk A, Ding D, Crowley RW, Liu KC, Chalouhi N, et al.: Technology developments in endovascular treatment of intracranial aneurysms. J Neurointerv Surg 8:135144, 2016

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29

    Weisz G, Metzger DC, Caputo RP, Delgado JA, Marshall JJ, Vetrovec GW, et al.: Safety and feasibility of robotic percutaneous coronary intervention: PRECISE (Percutaneous Robotically-Enhanced Coronary Intervention) Study. J Am Coll Cardiol 61:15961600, 2013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

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