Hello, and welcome to the September 2019 edition of Vascular Disease Management. I have chosen to comment on Dr John Phillips’ case presentation in which he utilized the Corindus robotic system to revascularize an occluded posterior tibial artery. This artery had an aberrant origin via the popliteal artery. The patient had an ischemic plantar ulcer in the posterior tibial angiosome that had stalled in healing following prior vascular interventional therapy. Additionally, the patient had a known occlusion of the ipsilateral distal anterior tibial artery. The patient had underwent several prior limb salvage interventional procedures, and he had suboptimal anatomy for distal bypass, with poor distal arterial targets.
In this case report, ipsilateral antegrade femoral access was obtained, and a long-braided sheath was placed distally via standard technique. The patient was approached using robotic technique. A guiding catheter was placed into the posterior tibial artery, and a guidewire was advanced by an operator working at a remote workstation, away from radiation and without the need for heavy lead protective aprons. The wire was able to cross the totally occluded artery, after which balloon angioplasty resulted in satisfactory arterial recanalization. Dr Phillips pointed out the present limitations of the robotic system, including the need to use rapid-exchange devices rather than the typical over-the-wire support catheters used by most peripheral interventionists.
I have chosen to comment on this case because robotic approach peripheral vascular intervention shows potential to reduce the risks and shortcomings associated with peripheral intervention by lessening radiation exposure, providing better fluoroscopic screen visualization without neck contortion (the video screen is directly in front of the operator, at optimal distance), and potentially avoiding the discomfort and orthopedic risk of wearing heavy and restrictive lead protective devices.
Robotic approach also has the potential to provide more precise wire torque. Theoretically, with improved information transmission capabilities, experts may be able to assist others in complex interventions at remote sites and have no significant latency image distortion. Present iteration devices have limitations. These devices do not provide tactile feedback, do not allow remote advancement of over-the-wire drug-coated balloons or stents, and require that technologists exchange devices at the bedside. The robotic devices are expensive, and, at this time, they do not reduce procedural times. Safety and comfort are currently the primary advantages of remote procedures. However, with the development of newer rapid-exchange devices, as well as adaptations made to allow use of over-the-wire devices, I believe that robotic crossing and treatment has the potential to improve crossing and treatment success.
I can envision modifications that will allow precise catheter and wire rotation, controlled advancement of treatment devices to allow safer and more effective therapy, and tactile and information feedback from the device tip to further guide interventional therapy. Robotic control has the potential to reduce the risk of inadvertent distal migration of guidewires, which can result in distal vessel injury, and to reduce the risk of inadvertent loss of wire position across the treatment area with device exchange. Robotic peripheral vascular interventions have great promise, but they will need continued study and development. I believe the robotic approach has the potential to improve care.