Transcarotid access for remote robotic endovascular neurointerventions: a cadaveric proof-of-concept study

Abstract

OBJECTIVE The purpose of this proof-of-concept study was to demonstrate the setup and feasibility of transcarotid access for remote robotic neurointerventions in a cadaveric model. METHODS The interventional procedures were performed in a fresh-frozen cadaveric model using an endovascular robotic system and a robotic angiography imaging system. A prototype remote, robotic-drive system with an ethernet-based network connectivity and audio-video communication system was used to drive the robotic system remotely. After surgical exposure of the common carotid artery in a cadaveric model, an 8-Fr arterial was inserted and anchored. A telescopic guiding sheath and catheter/microcatheter combination was modified to account for the “workable” length with the CorPath GRX robotic system using transcarotid access. RESULTS To simulate a carotid stenting procedure, a 0.014-inch wire was advanced robotically to the extracranial internal carotid artery. After confirming the wire position and anatomy by angiography, a self-expandable rapid exchange nitinol stent was loaded into the robotic cassette, advanced, and then deployed robotically across the carotid bifurcation. To simulate an endovascular stroke recanalization procedure, a 0.014-inch wire was advanced into the proximal middle cerebral artery with robotic assistance. A modified 2.95-Fr delivery microcatheter (Velocity, Penumbra Inc.) was loaded into the robotic cassette and positioned. After robotic retraction of the wire, it was switched manually to a mechanical thrombectomy device (Solitaire X, Medtronic). The stentriever was then advanced robotically into the end of the microcatheter. After robotic unfolding and short microcatheter retraction, the microcatheter was manually removed and the stent retriever was extracted using robotic assistance. During intravascular navigation, the device position was guided by 2D angiography and confirmed by 3D cone-beam CT angiography. CONCLUSIONS In this proof-of-concept cadaver study, the authors demonstrated the setup and technical feasibility of transcarotid access for remote robot-assisted neurointerventions such as carotid artery stenting and mechanical thrombectomy. Using transcarotid access, catheter length modifications were necessary to achieve “working length” compatibility with the current-generation CorPath GRX robotic system. While further improvements in dedicated robotic solutions for neurointerventions and next-generation thrombectomy devices are necessary, the transcarotid approach provides a direct, relatively rapid access route to the brain for delivering remote stroke treatment.

Robotically performed diagnostic coronary angiography

“…Endovascular thrombectomy has been convincingly demonstrated to be superior to thrombolytic therapy for acute large vessel stroke, 23 but availability of catheter‐based stroke care is exceptionally limited in rural areas 19,22 . The development of remote robotic endovascular thrombectomy, which theoretically could disseminate the technical expertise to perform catheter‐based stroke interventions in rural geographies, is underway 24,25 …”

“…19,22 The development of remote robotic endovascular thrombectomy, which theoretically could disseminate the technical expertise to perform catheter-based stroke interventions in rural geographies, is underway. 24,25…”

Neuroendovascular robotics: wave of the future or failed promise?

“…Further, the catheter's range of motion in the GRX is only about 20 cm, meaning manual access up to the target pathology is required before robotic utilization. 9 In addition, the technological infrastructure required to support its real-time usage is significant and, while the CorPath GRX system provided the promise of expanding markets, it came at a significant price. The unit itself was estimated to cost $480 000-650 000, not to mention the peripheral costs of the single-use cassettes ($300-750) and the aforementioned on-site personnel and associated data infrastructure.…”