Johnson Francis, MBBS, MD, DM
Baby Memorial Hospital, Kozhikode, Kerala, India. PIN:
673004
Address for Correspondence: Prof. Dr. Johnson
Francis, MBBS, MD, DM, FCSI, FACC, FRCP Edin, FRCP London,
Senior Consultant Interventional Cardiologist, Baby Memorial
Hospital, Kozhikode, Kerala, India. PIN: 673004. E-mail:
pulikkottil2002@hotmail.com
Keywords: robotic enhanced percutaneous coronary
intervention, conventional percutaneous coronary intervention
Last issue of the Journal contained an article on the benefits
of robotic telesurgery [1]. Now we would like to examine
another aspect of robotics in medicine - Robotic enhanced
percutaneous coronary intervention (PCI). The first-in-humans
pilot clinical trial involving 18 patients was published in
2006 [2]. In this study angioplasty guidewire, balloon and
stents were navigated by a computerized system. The guidewire
could cross the lesion successfully in 17 cases and 15 of
these cases could be successfully completed by remote
navigation. The remaining 3 cases were completed manually. The
proposed advantages of the system was a significantly lower
radiation exposure to the operator and possibly more precise
positioning of the coronary stent. There was no increase in
fluoroscopy time.
After this initial pilot study several technological advances
have occurred in the remote navigation system. There is a
patient side cassette which drives the devices within the
vascular tree and a remote computerized console from which the
operator does the remote navigation. In the initial systems,
the operator console had only facility for device movements.
Angiographic monitors were at the bedside, at a distance from
the operator. Now the larger console has multiple monitors in
addition, to view the angiographic images with facility for
computerized lesion measurement and analysis. This would allow
better sizing of lesions and estimation of correct stent size
needed. Let us see how these advances have translated into
actual advantages to the patient and operator.
PRECISE (Percutaneous Robotically-Enhanced Coronary
Intervention) Study was the first large scale study of robotic
enhanced PCI involving 164 patients enrolled at 9 sites [3].
Technical success defined as successful manipulation of
intracoronary devices using the remote navigation system
alone, was achieved in 162 patients (98.8%). Clinical success
defined as residual coronary stenosis of less than 30% and
absence of major adverse cardiovascular events within 30 days
was achieved in 160 patients (97.6%). Four patients (2.4%) had
periprocedural non Q wave myocardial infarction. There
were no deaths, Q wave myocardial infarctions, stroke or
repeat myocardial revascularizations during the 30 days. The
remarkable feature was that radiation exposure was 95.2%
lesser than conventional procedure for the primary operator.
The fluoroscopy time and radiation exposure to the patient was
comparable to previous published values for conventional PCI.
There is an added advantage to the operator in avoiding the
heavy lead apron and potential orthopedic issues. Moreover a
sitting position at the console reduces the fatigue factor and
could enhance the ability to make better decisions. A sub
study of the same trial reported more complete and faster
robotic enhanced PCI, with reduced radiation while not
compromising safety after the initial 3 learning cases of each
operator [4].
After the initial demonstration of the feasibility of robotic
PCI, others have ventured into complex PCI with the robotic
system. Kapur V and colleagues used it for multi lesion and
multi vessel coronary artery disease, saphenous vein graft
intervention and in ST elevation myocardial infarction [5].
They documented enhanced visibility, precise lesion
measurement, accurate positioning of the stent and better
operator radiation protection with robotic PCI.
A comparison of 40 robotic enhanced PCI with 80 conventional
PCI has been published by Smilowitz NR et al [6]. Only two
robotic cases needed conversion to manual PCI. Robotic
enhanced PCI was associated with a trend towards lower
fluoroscopy time, radiation exposure and contrast
volume. The impact of precise lesion measurement in potential
stent saving has been studied by other investigators [7]. They
found that visual stent assessment was accurate only in 21 of
the 60 cases studied. In 5 cases, one stent could be saved by
robotic measurement compared to visual lesion length
assessment. On similar lines, another group of workers showed
that robotic enhanced PCI had a significantly lower
longitudinal geographic miss compared to conventional PCI [8].
But for the equipment cost, robotic enhanced PCI seems to be a
good option both for the operator and subject. We need more
studies on hard end points and long term benefits of robotic
enhanced PCI to justify the added cost before it can be made a
universal recommendation.
References
1. Johnson B, Somu G. Robotic Telesurgery: Benefits Beyond
Barriers. BMH Medical Journal 2016;3(2):51-54.
2. Beyar R, Gruberg L, Deleanu D, Roguin A, Almagor Y, Cohen
S, Kumar G, Wenderow T. Remote-control percutaneous coronary
interventions: concept, validation, and first-in-humans pilot
clinical trial. J Am Coll Cardiol. 2006 Jan 17;47(2):296-300.
3. Weisz G, Metzger DC, Caputo RP, Delgado JA, Marshall JJ,
Vetrovec GW, Reisman M, Waksman R, Granada JF, Novack V, Moses
JW, Carrozza JP. Safety and feasibility of robotic
percutaneous coronary intervention: PRECISE (Percutaneous
Robotically-Enhanced Coronary Intervention) Study. J Am Coll
Cardiol. 2013 Apr 16;61(15):1596-600.
4. Weisz G, Smilowitz NR, Metzger DC, Caputo
R, Delgado J, Marshall JJ,Vetrovec G, Reisman
M, Waksman R, Pichard A, Granada JF, Moses
JW,Carrozza JP. The association between experience and
proficiency with robotic-enhanced coronary
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study. Acute Card Care. 2014 Jun;16(2):37-40.
5. Kapur V, Smilowitz NR, Weisz G.
Complex robotic-enhanced percutaneous coronary
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6. Smilowitz NR, Moses JW, Sosa FA, Lerman
B, Qureshi Y, Dalton KE,Privitera
LT, Canone-Weber D, Singh V, Leon
MB, Weisz G. Robotic-Enhanced PCI Compared to
the Traditional Manual Approach. J Invasive Cardiol. 2014
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7. Campbell PT, Kruse KR, Kroll CR, Patterson
JY, Esposito MJ. The impact
of precise robotic lesion length measurement on
stent length selection: ramifications for stent savings.
Cardiovasc Revasc Med. 2015 Sep;16(6):348-50.
8. Bezerra HG, Mehanna E, W Vetrovec G, A Costa
M, Weisz G. Longitudinal Geographic Miss (LGM)
in RoboticAssisted Versus Manual Percutaneous Coronary
Interventions. J Interv Cardiol. 2015 Oct;28(5):449-55.