Purpose
Endovascular robotics is an emerging technology within the developing field of medical robotics. This was a prospective evaluation to assess safety and feasibility of robotic-assisted carotid ...artery stenting.
Materials and Methods
Consecutive cases of carotid artery stenting cases performed over period of 24 months, from May 2015 to October 2016, using the Magellan Robotic System (Hansen, Mountain View, CA) were included. All cases utilised the robotic system to navigate the arch, obtain a stable position in the common carotid artery, followed by manual manipulation of Embolic Protection Devices and self-expandable stents through the robotic catheter. Patients demographics, clinical indications, anatomical features, technical and clinical success, complication rate and hospital stay were prospectively recorded.
Results
Thirteen patients, 10 males (78.5%), with an average age of 68.7 years were treated. Mean follow up time was 30 months. Ten patients (91%) were symptomatic at presentation. Anatomical indications for endovascular stent insertion were previous open surgery to the neck ± radiotherapy (87.5%) and hostile anatomy for open surgery (12.5%). Technical success was 100% and the robotic system demonstrates enhanced stability during arch and lesion crossing. There were no neurological complications post-operatively. Average hospital stay was 3 days (range 2–6 days) and a change in serum creatinine of −7.8 μmol/L. There was no documented case of in stent restenosis, new or worsening neurology during follow-up.
Conclusion
These results illustrate safety and feasibility of robotic endovascular revascularisation for carotid disease and demonstrates potential to enhance peri-procedural safety through improved control and stability.
Background Emerging robotic technologies are increasingly being used by surgical disciplines to facilitate and improve performance of minimally invasive surgery. Robot-assisted intervention has ...recently been introduced into the field of vascular surgery to potentially enhance laparoscopic vascular and endovascular capabilities. The objective of this study was to review the current status of clinical robotic applications in vascular surgery. Methods A systematic literature search was performed in order to identify all published clinical studies related to robotic implementation in vascular intervention. Web-based search engines were searched using the keywords “surgical robotics,” “robotic surgery,” “robotics,” “computer assisted surgery,” and “vascular surgery” or “endovascular” for articles published between January 1990 and November 2009. An evaluation and critical overview of these studies is reported. In addition, an analysis and discussion of supporting evidence for robotic computer-enhanced telemanipulation systems in relation to their applications in laparoscopic vascular and endovascular surgery was undertaken. Results Seventeen articles reporting on clinical applications of robotics in laparoscopic vascular and endovascular surgery were detected. They were either case reports or retrospective patient series and prospective studies reporting laparoscopic vascular and endovascular treatments for patients using robotic technology. Minimal comparative clinical evidence to evaluate the advantages of robot-assisted vascular procedures was identified. Robot-assisted laparoscopic aortic procedures have been reported by several studies with satisfactory results. Furthermore, the use of robotic technology as a sole modality for abdominal aortic aneurysm repair and expansion of its applications to splenic and renal artery aneurysm reconstruction have been described. Robotically steerable endovascular catheter systems have potential advantages over conventional catheterization systems. Promising results from applications in cardiac interventions and preclinical studies have urged their use in vascular surgery. Although successful applications in endovascular repair of abdominal aortic aneurysm and lower extremity arterial disease have been reported, published clinical experience with the endovascular robot is limited. Conclusions Robotic technology may enhance vascular surgical techniques given preclinical evidence and early clinical reports. Further clinical studies are required to quantify its advantages over conventional treatments and define its role in vascular and endovascular surgery.
A 67-year-old man underwent robot-assisted three-vessel fenestrated endovascular aneurysm repair (FEVAR) for a 7.3-cm juxtarenal aneurysm. The 6-F robotic catheter was manipulated from a remote ...workstation, away from the radiation source. Robotic cannulation of the left renal artery was achieved within 3 minutes. System setup time was 5 minutes. There were no postoperative complications. Computed tomography angiography performed at discharge and at 4-month follow-up confirmed target vessel patency with no evidence of an endoleak. Selective cannulation of target vessels during FEVAR using this novel technology is feasible. Endovascular robotics may have a role in simplifying complex endovascular tasks and potentially reducing radiation exposure to the operator.
BACKGROUND:The 21st century has witnessed a rise in the use of endovenous thermal ablation. Being highly clinically and cost-effective and improving the quality of life of patients, they are now ...considered to be the “gold-standard” treatment for varicose veins. Post-intervention management, especially in terms of postoperative compression, however, remains unclear. As a result, a randomized study was undertaken to investigate the effects of wearing compression stockings after varicose vein treatment.
METHOD:Patients with saphenous vein reflux undergoing treatment with endothermal ablation (with or without concurrent phlebectomies) were randomized to receive either 7 days of compression stockings or no stockings. The primary outcome measure for this study was the pain score over the first 10 postoperative days. The pain scores, clinical score, time to return to normal activities, and ecchymosis were assessed. Patients were followed-up at 2 weeks and 6 months post-ablation.
RESULTS:In total, 206 patients were randomized, 49% of them to the compression group. The mean age was 49.7 (±16) years and approximately 51% of the population was male. The median pain score in the compression group using a visual analog scale was significantly lower on days 2–5, compared to the no compression group. Those having concurrent phlebectomies and compression stockings also had significantly better pain scores on days 1–3, day 5, and day 7. Improvement in the median venous clinical severity score was noted at 6-month follow-up, but this was not significant. No difference in the generic- or disease-specific quality of life was observed and the time to return to activities was similar. There were no differences in the degree of ecchymosis between the 2 groups and both groups had similar occlusion rates.
CONCLUSIONS:These results indicate that wearing compression stockings after endothermal ablation is advantageous in the first few days after treatment and is especially beneficial for those having concurrent phlebectomies.
Objective Conventional catheter instability and embolization risk limits the adoption of endovascular therapy in patients with challenging arch anatomy. This study investigated whether arch vessel ...cannulation can be enhanced by a remotely steerable robotic catheter system. Methods Seventeen clinicians with varying endovascular experience cannulated all arch vessels within two computed tomography-reconstructed pulsatile flow phantoms (bovine type I and type III aortic arches), under fluoroscopic guidance, using conventional and robotic techniques. Quantitative (catheterization times, catheter tip movements, vessel wall hits, catheter deflection) and qualitative metrics (Imperial College Complex Endovascular Cannulation Scoring Tool IC3ST) performance scores were compared. Results Robotic catheterization techniques resulted in a significant reduction in median carotid artery cannulation times and the median number of catheter tip movements for all vessels. Vessel wall contact with the aortic arch wall was reduced to a median of zero with robotic catheters. During stiff guidewire exchanges, robotic catheters maintained stability with zero deflection, independent of the distance the catheter was introduced into the carotid vessels. Overall IC3ST performance scores (interquartile range) were significantly improved using the robotic system: Type I arch score was 26/35 (20-30.8) vs 33/35 (31-34; P = .001), and type III arch score was 20.5/35 (16.5-28.5) vs 26.5/35 (23.5-28.8; P = .001). Low- and medium-volume interventionalists demonstrated an improvement in performance with robotic cannulation techniques. The high-volume intervention group did not show statistically significant improvement, but cannulation times, movements, and vessel wall hits were significantly reduced. Conclusion Robotic technology has the potential to reduce the time, risk of embolization and catheter dislodgement, radiation exposure, and the manual skill required for carotid and arch vessel cannulation, while improving overall performance scores.
Objective Conventional catheter manipulation in the arch and supra-aortic trunks carries a risk of cerebral embolization. This study proposes a platform for detailed quantitative analysis of contact ...forces (CF) exerted on the vasculature, in order to investigate the potential advantages of robotic navigation. Methods An anthropomorphic phantom representing a type I bovine arch was mounted and coupled onto a force/torque sensor. Three-axis force readings provided an average root-mean-square modulus, indicating the total forces exerted on the phantom. Each of the left subclavian, left common carotid, and right common carotid arteries was cannulated within a simulated endovascular suite with conventional (n = 42) vs robotic techniques (n = 30) by two operator groups: experts and novices. The procedure path was divided into three phases, and performance metrics corresponding to mean and maximum forces, force impact over time, standard deviation of forces, and number of significant catheter contacts with the arterial wall were extracted. Results Overall, median CF were reduced from 1.20 N (interquartile range IQR, 0.98-1.56 N) to 0.31 N (IQR, 0.26-0.40 N; P < .001) for the right common carotid artery; 1.59 N (IQR, 1.11-1.85 N) to 0.33 N (IQR, 0.29-0.43 N; P < .001) for the left common carotid artery; and 0.84 N (IQR, 0.47-1.08 N) to 0.10 N (IQR, 0.07-0.17 N; P < .001) for the left subclavian artery. Robotic navigation resulted in significant reductions for the mean and maximum forces for each procedural phase. Significant improvements were also seen in other metrics, particularly at the target vessel ostium and for the more anatomically challenging procedural phases. Force reductions using robotic technology were evident for both novice and expert groups. Conclusions Robotic navigation can potentially reduce CF and catheter-tissue contact points in an in vitro model, by enhancing catheter stability and control during endovascular manipulation.
BACKGROUND:SSMD are used to enhance transparency, improve quality and facilitate patient choice. The use of SSMD is controversial, but patients’ views on such data are largely unknown.
OBJECTIVES:The ...aim of this study was therefore to explore the views of patients and to identify their priorities for outcome reporting in vascular surgery.
METHODS:A prospective questionnaire study of 165 patients receiving care in a single academic vascular unit was performed. Data on patients’ current understanding and use of SSMD, together with future priorities were collected.
RESULTS:Of the 165 patients 80% were unaware of SSMD. 72% thought they should be made aware of the data, although 63% thought they were likely to misinterpret the results. The majority recognized the utility of SSMD to inform treatment (60%) and surgeon (53%) choice. The majority prioritize the patient-surgeon relationship (90%) and past experiences of care (71%) when making treatment decisions. A significant majority (66% vs 49%; P < 0.005) would favour hospital-level to surgeon-level data. The main patient priorities for future outcome reporting were waiting list length (56%), the quality of hospital facilities (55%), and patient satisfaction (54%).
CONCLUSIONS:The aims of SSMD reporting are not currently being met, and both patients and healthcare professionals have shared concerns over the nature and usefulness of the data. Patients express a preference for hospital-level outcomes and prioritize the experience of receiving care over outcomes when making treatment decisions. Future outcome reporting should include patient-directed hospital-level metrics that are readily accessible and understood by all.
Objective Type B aortic dissection can be acutely complicated by rapid expansion, rupture, and malperfusion syndromes. Short-term adverse outcomes are associated with failure of the false lumen to ...thrombose. The reasons behind false lumen patency are poorly understood, and the objective of this pilot study was to use computational fluid dynamics reconstructions of aortic dissection cases to analyze the effect of aortic and primary tear morphology on flow characteristics and clinical outcomes in patients with acute type B dissections. Methods Three-dimensional patient-specific aortic dissection geometry was reconstructed from computed tomography scans of four patients presenting with acute type B aortic dissection and a further patient with sequential follow-up scans. The cases were selected based on their clinical presentation. Two were complicated by acute malperfusion that required emergency intervention. Three patients were uncomplicated and were managed conservatively. The patient-specific aortic models were used in computational simulations to assess the effect of aortic tear morphology on various parameters including flow, velocity, shear stress, and turbulence. Results Pulsatile flow simulation results showed that flow rate into the false lumen was dependent on both the size and position of the primary tear. Linear regression analysis demonstrated a significant relationship between percentage flow entering the false lumen and the size of the primary entry tear and an inverse relationship between false lumen flow and the site of the entry tear. Subjects complicated by malperfusion had larger-dimension entry tears than the uncomplicated cases (93% and 82% compared with 32% and 55%, respectively). Blood flow, wall shear stress, and turbulence levels varied significantly between subjects depending on aortic geometry. Highest wall shear stress (>7 Pa) was located at the tear edge, and progression of false lumen thrombosis was associated with prolonged particle residence times. Conclusions Results obtained from this preliminary work suggest that aortic morphology and primary entry tear size and position exert significant effects on flow and other hemodynamic parameters in the dissected aorta in this preliminary work. Blood flow into the false lumen increases with increasing tear size and proximal location. Morphologic analysis coupled with computational fluid dynamic modeling may be useful in predicting acute type B dissection behavior allowing for selection of proper treatment modalities, and further confirmatory studies are warranted.
Purpose
To investigate the quality of stent-graft fenestrations created in vitro
using different needle puncture and balloon dilation angles in different
commercial endografts.
Methods
Fenestrations ...were made in a standardized fashion in 3 different endograft
types: Talent monofilament twill woven polyester, Zenith multifilament
tubular woven polyester, and Endofit thin-walled expanded
polytetrafluoroethylene (PTFE). Punctures were made at 30°,
60°, and 90° angles using a 20-G needle and dilated using 6-mm
standard and 7-mm cutting balloons; at least 6 fenestrations were made at
each angle with standard balloons and at least 6 with cutting balloons. The
137 fenestrations were examined under light microscopy; quantitative and
qualitative digital image analysis was performed to determine size, shape,
and fenestration quality.
Results
PTFE grafts were easier to puncture/dilate, resulting in larger, elliptical
fenestrations with overall better quality than the Dacron grafts; however,
the puncture/dilation angle made an impact on the shape and quality of
fenestrations. A significant number of fabric tears were observed in PTFE
fabric at <90° puncture/dilation angles compared to Dacron
grafts. In Dacron grafts, fenestration quality was significantly higher with
90° puncture/dilation angles (higher in Talent grafts). Cutting
balloon use resulted in significantly more fabric tears and poor quality
fenestrations in all graft types.
Conclusion
Different endografts behave significantly differently when fenestrations are
fashioned. Optimum puncture/dilation is important when considering in vivo
fenestration techniques. Improvements in instrumentation, materials, and
techniques are required to make this a reliable and reproducible
endovascular option.
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