Lack of evidence among challenges that must be overcome to realise potential of robotic neurointerventions

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In spite of the clinical successes observed to date, a lack of high-level safety and efficacy evidence, among other current challenges and limitations, must be overcome in order to realise the potential held by robotics in neurointerventional surgery. This is the concluding view outlined in a systematic literature review published in the Journal of NeuroInterventional Surgery (JNIS) by Thomas Booth, William Crinnion (both School of Biomedical Engineering and Imaging Sciences, King’s College London, London, UK) and colleagues.

“It is plausible that robotically performed neurointerventional procedures will eventually benefit patients and reduce occupational hazards for staff; however, there is no high-level efficacy and safety evidence to support this assertion,” Booth, Crinnion et al write in JNIS. “If robust efficacy and safety evidence emerges, and if proved to be cost-effective, one potential use would be for a fully functioning platform to perform teleoperated intervention—which, if applied to MT [mechanical thrombectomy] in stroke, would accelerate the treatment of eligible patients in locations that are at a considerable distance from the operator.

“Potential platforms currently require considerable refinement. First, to ensure that minimal interventional input is required by an operator within the operating room. Second, to allow the precise use of a wide range of neurovascular microcatheters and devices. Third, to develop haptic feedback systems that directly match manual operator movements; this has the potential to reduce training time, make use of the operator’s pre-existing skills, and mitigate risks from catheter and wire damage through the appreciation of subtle catheter and wire movements.”

These conclusions were drawn by Booth, Crinnion and colleagues following a systematic review of existing literature in this space, which included articles published before or on 12 April 2021, and sourced through the Medline, PubMed, Embase and Cochrane databases. After screening a total of 145 articles, the authors note that eight articles—treating 81 patients—met their eligibility criteria and were included for qualitative and quantitative analysis.

They state that seven of these studies reported the use of robotic systems for diagnostic cerebral angiography or carotid artery stenting (CAS), and one case report described the use of a robotic system performing intracranial intervention. Manual conversion was required in three cases across these articles, giving a technical success rate of 96% (78/81). There were also no pertinent morbidity- or mortality-related safety data or complications reported in any of the studies, resulting in a clinical success rate of 100%.

Only one study performed a comparison between robotically assisted and completely manual procedures, they add—and found a significant increase in procedure times associated with robotic CAS. However, Booth, Crinnion and colleagues also temper these largely positive findings by noting that all the evidence identified here falls into the category of level-four evidence, adding that, as such, there is currently no high-level evidence to demonstrate that robotically performed neurointervention is at least non-inferior to manual procedures.

But, despite this low level of existing evidence, they continue, there is still value in discussing these individual studies further—not least because “they represent the current state of the art and form a baseline for further research”. In their report, Booth, Crinnion and colleagues also highlight the various pros and cons associated with the Magellan robotic system (Hansen Medical/Auris Health), the CorPath GRX system (Corindus/Siemens Healthineers), and a further two experimental robotic systems, all of which featured in the eight articles.


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