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Remote robotic-assisted technology could change future of PCI
The concept of robotic-assisted PCI has been successfully implemented since 2011, allowing for precise navigation of catheters and stents while reducing radiation-related risks.
The technology (CorPath GRX, Corindus Vascular Robotics/Siemens) has now advanced to the point where it can be used remotely. If successful, this approach could enable patients in rural areas with few operators to receive PCI in a manner as timely as those in more populated areas.
To test the feasibility of remote robotic-assisted PCI, Tejas M. Patel, MD, DM, FACC, FSCAI, FESC, chairman and chief interventional cardiologist at Apex Heart Institute in Ahmedabad, India, and colleagues performed PCI on five patients with type A coronary artery lesions from a site 20 miles away.
According to a report in The Lancet’s EClinicalMedicine published in September, the primary endpoint of procedural success without MACE before discharge was achieved in all five patients. Procedural success was defined as achievement of percent diameter stenosis < 10% in the target vessel without conversion to in-lab manual PCI. All operators involved rated the procedure as equivalent to in-lab manual PCI.
Patel spoke with Healio about how the procedures worked and how the technology might help shape the future of PCI.
Question: How does this technology work?
Answer: The CorPath GRX system increases procedural control via robotic-assisted operation of guide catheters, guidewires and balloon/stent catheters. For CV intervention, at the beginning of a procedure, a guide catheter device is inserted through a patient’s femoral artery in the groin or radial artery in the wrist and guided to the heart or peripheral vasculature. The guide wire and balloon/stent is then transported through the guide catheter to the affected region using the CorPath GRX’s robotic system. Once the balloon or stent is placed in the narrowed artery, the physician will inflate the balloon to open the blockage and restore blood flow.
Q: What kind of learning curve does an operator go through when using this technology?
A: My cath lab crew, headed by Yash Soni, is very competent and was extremely enthusiastic to adopt to any new technology. It was a matter of only 10 robotic cases for them to surmount their learning curve. Nowadays, my crew takes less than 1 minute to prepare the robot. I am very thankful to Joe Aquilina, senior manager of international sales and training at Corindus, to offer his time and energy for training my crew.
Q: What are the advantages of using this technology?
A: The CorPath GRX provides a sense of comfort to me and the rest of my staff, allowing us to practice robotic-assisted PCI with the highest level of accuracy and precision while also increasing our confidence in wiring real complex lesions. Robotic-assisted procedures with the CorPath GRX provides unmatched precision, leading to better outcomes and fewer readmissions. Additionally, the radiation exposure to myself and the rest of our cath lab staff is at a record low. By working in the radiation-protected console with a large, high-definition monitor, as opposed to at the operating table, visual and physical fatigue is drastically reduced, allowing us to practice longer and more effectively.
Q: Under which circumstances is this technology most likely to be used?
A: CVD, including stroke, is the world’s most significant and undertreated clinical problem due to limited access to specialized, timely medical care. The CorPath GRX is used in vascular procedures and aims to break down existing barriers to care, including increased global poverty and a declining number of trained specialists. Only a fraction of patients worldwide receive lifesaving treatment, resulting in substantial death or disability for the remaining patients. With technology like the CorPath GRX, physicians can perform lifesaving procedures on patients outside of their reach.
We started doing robotic-assisted PCI on Dec. 5, 2017. In initial robotic-assisted PCI cases, we were very careful in case selection, ie, we chose only type A or B1 lesions. We made sure that the lesions we re in the proximal or mid segment, and that there was no calcium or thrombus or significant tortuosity. Slowly as we started becoming comfortable, we encroached upon more and more difficult cases. After 50 cases, we became comfortable with many difficult subsets including type B2 and type C lesions, selected cases of acute MI, selected cases of chronic total occlusion and even a few of the bifurcation cases. As artificial intelligence will become more incorporated in the system, even more difficult cases will be done with lots of comfort and ease. As of now we have experienced 450 robotic PCI cases in the span of about 18 months.
Q: What were the major lessons learned from these first cases?
A: It was a wonderful experience for me and my team to perform five PCIs using remote technology. All five cases worked flawlessly. However, it was first-in-human study, hence as per the protocol we chose relatively straightforward lesions. With further refinement of this technology and incorporation of AI, we should be able to address more and more difficult cases remotely. I am dreaming of a remote console in size of a briefcase that can easily be carried by an interventional cardiologist or an interventional neuroradiologist who can perform remote PCI or remote stroke management sitting in any corner of the world.
Q: What are the next steps from here?
A: This technology has a very bright future. After incorporation of more and more AI, the technology will make the interventions simpler and simpler. There will be less and less scope for human errors. Once telerobotic stenting standardizes, the distance between a cardiologist and the patient will not matter. Sitting anywhere in the world, a cardiologist will be able to fix the blocks of the patient in a cath lab having CorPath GRX. Ultimately, this technology will become the way of life for interventional cardiologists and interventional neuroradiologists. – by Erik Swain
Reference:
Patel TM, et al. EClinicalMedicine. 2019;doi:10.1016/j.eclinm.2019.07.017.
For more information:
Tejas M. Patel, MD, can be reached at tejaspatel@apexheart.in.
Disclosure: The study was funded by Corindus Vascular Robotics, now part of Siemens. Patel reports he is a consultant for Corindus Vascular Robotics.