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conduit, harvested from other areas of the body, mostly the
great saphenous or cephalic veins. The idea conduit should
be at least 3mm in diameter [6]. Following harvesting of the
conduit, the vein is reversed and tunnelled before anastomosing with the inow artery and target vein. The site of anastomosis between the conduit and target vein is usually done at
the level of the ankle. Polytetrauorethylene (PTFE) conduits are an alternative to harvested veins and less commonly
used to achieve a bypass. After a satisfactory anastomosis
has been achieved, valvulotomy is performed on the distal
target veins.
Endovascular Approach toDVA
Unlike in open techniques, the mainstay of endovascular
DVA is to create a stulous connection between an adjacent
artery and vein. Most common sites for this are the posterior
tibial artery and vein, and less commonly the anterior tibial
vessels. Venous access is performed. This can either be
directly into the PT or AT vein, or alternatively into a pedal
vein. If accessing the PT vein, pedal access has the advantage that wire access across the distal PT at the ankle is
achieved, which facilitates venoplasty of the valve at the
level of the ankle, which can be a challenging site to otherwise deal with. A wire is then navigated to the cross-over
point at which point the anastomosis will be created.
Antegrade arterial access is obtained, typically via the ipsilateral common femoral artery, and a wire navigated to the
cross-over point. The stulous connection is then created by
means of a re-entry device. Both uoroscopic-guided catheters (e.g. Outback, Cordis) and Intravascular ultrasound
(IVUS)-guided (e.g. Pioneer Plus, Phillips) catheters have
been used. These systems are inserted down the arterial
access and utilise a side-angled needle to puncture trough the
arterial wall into the vein (Figs.12.2, 12.3, and 12.4).
An angioplasty balloon can be inated in the vein to act as
a target for needle puncture. Once needle access into the vein
has been achieved, a through-and-through wire between the
arterial and venous access can be achieved. This may require
the use of an endovascular snare from the venous access to
capture and retrieve the wire.
The arteriotomy site is then serially pre-dilated, typically
from 2mm to 3–4mm to facilitate passage of further devices.
In some situations, if the crural artery is signicantly diseased, atherectomy may be performed to maximise inow.
Valvotomy must then be performed to ensure retrograde
ow down the arterialised vein must next be performed. This
is typically performed by venoplasty across the veins, and
may require use of high pressure, sculpting or cutting balloons to achieve sufcient valvotomy (Fig.12.5).
A covered stent graft is then deployed across the arteriotomy to maintain the stulous connection. At our institution,
B. Z. Khan et al.
Fig. 12.2 Venogram of the foot outow obtained following pedal
venous access during an endovascular DVA
Fig. 12.3 An Outback catheter has been positioned in the posterior
tibial artery and an angioplasty balloon inated in the adjacent posterior
tibial vein. The Outback needle has then been advanced under uoroscopy to puncture the balloon and obtain stulous access
we use a covered self-expanding stent, usually a 5 mm
Viabahn (Gore). The stent may extend distally in the vein to
just above the level of the ankle. The stent is then post dilated
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Fig. 12.4 Angioplasty of the stulous tract created by the re-entry
catheter
Fig. 12.5 A wire has been navigate from the arterial access through the
stulous connection between the posterior tibial artery and vein (note
the presence of a stent) and around the pedal venous arch into the anterior tibial vein. Venoplasty is then performed to disrupt the valves in the
arterialised vein. Note the waisting of the balloon at the site of the posterior tibial valve at the level of the ankle—often a relatively resistant
site
Fig. 12.6 Completion angiography via injection from the posterior
tibial artery showing the complete DVA circuit with a stented posterior
tibial vein. Contrast can be seen passing through the pedal venous loop
into the outow anterior tibial vein
across the arteriotomy and into the vein to 5mm, and proximally at the arterial side to 4mm.
Venous outow must then be optimised. Now the stulous connection is secure, the venous access can be removed.
Low pressure ballooning across the venous access site may
be required for haemostasis. A wire can then be navigated
around a pedal venous loop, ideally into an outow vein,
such as the long saphenous vein. Further valvotomy may be
required to optimise the vascular loop. Arterial access can
then be secured and the patient observed as per local protocols (Fig.12.6).
The LimFlow system was introduced in 2012 and has
been designed as a complete kit to help perform percutaneous DVA.It was rst used in a patient in 2013. Since then
the LimFlow system has undergone three various studies.
These are the PROMISE I, ALPS Post Market and the
ongoing PROMISE II studies. Centres across the world
have become more accustomed to this system since its
introduction a decade ago. The LimFlow kit consist of the
following:
1. Limow arterial catheter
2. Limow venous catheter (consists of a radio opaque
mesh which once expanded enables better visualisation
of the target vein)
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B. Z. Khan et al.
3. Limow Valvulotome (forward facing hook with a cutting basket allows safer removal of venous valves as compared to traditional high pressure venoplasty which can
damage the venous walls)
4. Limow Stents (Crossing and Extension)
The LimFlow system is currently in its second iteration
since its introduction. The second generation system no longer utilises US guidance to ensure alignment of the arterial
and venous catheters, instead it relies on uoroscopic guidance only. It is currently undergoing further study in the
PROMISE II trial which is looking into wound healing rates
and amputation free survival in patients undergoing DVA for
CLTI.
Post Procedural Care Aspects
forEndovascular DVA
It is generally accepted that an endovascular DVA takes
4–6weeks to mature. Surveillance and medical optimisation
is key during this period. Patients require close follow-up in
the immediate aftermath of the procedure to check for any
reversible complications. This consists of clinical examination of the foot to assess the state of wounds and sonographic
assessment of the lower limb vessels and stent to assess
patency and ow. Volume ow (VF) and peak systolic velocity (PSV) have been identied as measurements to take when
performing an US follow-up. This practice has been adopted
from data gathered on follow-up of infra-inguinal bypasses
and arteriovenous stulas due to the similar anatomical and
physiological changes secondary to this intervention. Schreve
etal. recommends taking VF and PSV measurements at ve
points, these include the inow artery, proximal third, middle
third, distal third parts of the stent and the distal out ow vein
greater than 3cm from the distal end of the stent [7]. They
also suggest that the VF and PSV values are most reliable at
the middle third of the venous stent (Table12.4).
As with any endovascular procedure involving placement
of PTFE stents for prolonged periods, it is recommended to
place patients on a combination of dual platelet therapy. The
evidence for this is applied from studies investigating longterm effects of placing stents in lower limb vessels and not on
a specic randomised controlled trial investigating best post
procedural pharmacological practice on patient with a DVA.
Outcomes andComplications
ofEndovascular DVA
Common parameters used to assess outcomes in patients
undergoing DVA include patency of the circuit, limb salvage,
amputation-free survival (AFS), wound healing (WH) and
resolution of rest pain. Current literature indicates patency at
6months ranges from 29% to 40% [8, 9]. The PROMISE I
early feasibility trial was a single arm, prospective multicentre study investigating outcomes of DVAs performed
with the use of the LimFlow system. Table12.5 below shows
results from the study.
At 24months the PROMISE I trial also demonstrated a limb
salvage rate of 77% [10]. Another study suggested limb salvage
rates as high as 86% [11] with one study suggesting 100%
resolution in rest pain [8]. The ALPS multicentre study investigated the midterm results of percutaneous DVA with the
LimFlow system in 32 patients. It reported a median time of
4.9months to achieve complete wound healing [12]. Table12.6
highlights the results from the ALPS study at 6, 12 and
24months. Another smaller study consisting of ve patients
suggested a median wound healing time of 39weeks [8].
Table 12.7 shows results from the DEPARTURE study
which also investigated 12-month outcomes of percutaneous
DVA in 18 patients.
The DEPARTURE study also reported that median time
to complete wound healing was 234days [13]. The PROMISE
II study is currently on going and is further investigating
AFS and WH in patients undergoing DVA with the LimFlow
system for no options CLTI.
Reported complications in current literature include instent thrombosis/stenoses and failure to revascularise the
Table 12.5 demonstrates AFS and WH results from the PROMISE I
study [10]
Follow-up (months) AFS (%) Wound healing (%)
6 74 67
12 70 75
24 59 92
Table 12.6 shows AFS, LS and WH results from the ALPS study [12]
Follow-up
(Months)
6 83.9 86.8 36.6
12 71 79.8 68.2
24 67.2 79.8 72.7
AFS
(%)
Limb Salvage
(%)
Wound Healing
(%)
Table 12.4 shows VF and PSF values used in follow-up of DVA to
assess circuit [7]
Volume ow (mL/
Prediction
Patency >364 >99
Occlusion/
stenosis
min)
<195 <55
Peak systolic ow
(cm/s)
Table 12.7 shows AFS, LS and WH from the DEPARTURE study
[13]
Follow-up
(months)
6 55.6 72.2 23.0
12 49.4 72.2 53.2
AFS
(%)
Limb Salvage
(%)
Wound Healing
(%)
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foot. Schmidt etal. reported a median time of 2.6months to
occlude the DVA circuit [12]. Reintervention may be required
to try and address this. Stent stenosis or poor outow due to
persistent venous valves have also been reported as reasons
for reintervention aside from thrombotic occlusion. Current
literature suggests a reintervention rate between 53% and
71% [9, 12]. It is also possible that despite adequate arterialisation of the more proximal aspect of the lower limb vein,
there is insufcient ow to the more distal venous beds due
to competing venous outow. In these circumstances, coiling
or ablation of the competing veins has been performed, to
optimise arterialised ow to the foot.
Conclusion andFuture Directions
DVA is an evolving technique, which shows promise for
patients with CLTI where conventional revascularisation techniques have failed. It is a challenging eld and should only be
performed by operators experienced in endovascular CLTI
therapies and in carefully selected patients. There in ongoing
innovation in this eld, including in the development of a specically developed system for formation of the arteriovenous
conduit and valvotomy (LimFlow), although this is not yet
commercially available. Ongoing research, including assessment of the heath economic impact of this technique will be
valuable in helping to assess which patients will most benet.
Equipment Required toPerform aDVA
(Table12.8)
Table 12.8 Example of equipment used to perform DVA
Item Function
Introducer set
•Lidocaine 1%
•Scalpel
•Introducer needle
•Dilator
•Guidewire
•Femoral access sheath
Guidewires
•Terumo—Glide wire advantage
hydrophilic coated (180, 300cm)
•Abbott hi-torque command
(190/300cm)
•Boston Scientic—V18 control
wire (110, 150, 200, 300cm)
Flush and selective catheters
•Outback Cordis re-entry
catheter
•Pioneer plus IVUS guided
re-entry catheter
Balloon catheters Plasty of arteriovenous stula,
Covered stents
•GORE VIABAHN
Establish and secure arterial
and venous access
Manoeuvre to site of
arteriovenous stula
Cannulating and manoeuvre to
site of arteriovenous stula
Create stula between artery
and vein
destroy venous valves
Ensure patency of the DVA
circuit
References
1. Halstead AE, Vaughan RT. Arteriovenous anastomosis in the
treatment of gangrene in the extremities. Surg Gynecol Obstet.
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2. Francois-Franck M. Note à propos de la communication de M
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3. Lechareas S, Sritharan K, Williams RGM. Early and eighteen
month clinical outcomes of rst UK case of percutaneous deep
vein arterialisation (pDVA) to treat "no option" chronic limbthreatening ischemia using the LimFlow system. CVIR Endovasc.
2021;4(1):62. https://doi.org/10.1186/s42155- 021- 00252- 4.
4. Sheil GR. Treatment of critical ischaemia of the lower limb by
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A, Sidawy AN, Andros G. Society for Vascular Surgery Lower
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Surgery Lower Extremity Threatened Limb Classication System:
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(WIfI). J Vasc Surg. 2014;59(1):220–34. https://doi.org/10.1016/j.
jvs.2013.08.003. Epub 2013 Oct 12
6. Ho VT, Gologorsky R, Kibrik P, Chandra V, Prent A, Lee J, Dua
A.Open, percutaneous, and hybrid deep venous arterialization technique for no-option foot salvage. J Vasc Surg. 2020;71(6):2152–60.
https://doi.org/10.1016/j.jvs.2019.10.085. Epub 2019 Dec 31
7. Schreve MA, Huizing E, Kum S, de Vries JPM, de Borst GJ, Ünlü
Ç. Volume ow and peak systolic velocity of the arteriovenous
circuit in patients after percutaneous deep venous arterialization.
Diagnostics (Basel). 2020;10(10):760. https://doi.org/10.3390/
diagnostics10100760.
8. Del Giudice C, Van Den Heuvel D, Wille J, Mirault T, Messas E,
Ferraresi R, Kum S, Sapoval M.Percutaneous deep venous arterialization for severe critical limb ischemia in patients with no option
of revascularization: early experience from two European centers.
Cardiovasc Intervent Radiol. 2018;41(10):1474–80. https://doi.
org/10.1007/s00270- 018- 2020- 2. Epub 2018 Jul 17. Erratum in:
Cardiovasc Intervent Radiol. 2018 Jul 30.
9. Kum S, Huizing E, Schreve MA, Ünlü Ç, Ferraresi R, Samarakoon
LB, van den Heuvel DA. Percutaneous deep venous arterialization in patients with critical limb ischemia. J Cardiovasc
Surg. 2018;59(5):665–9. https://doi.org/10.23736/S0021-
9509.18.10569- 6. Epub 2018 May 22
10. Clair DG, Mustapha JA, Shishehbor MH, Schneider PA, Henao
S, Bernardo NN, Deaton DH.PROMISE I: early feasibility study
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jvs.2021.04.057. Epub 2021 May 18
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Ünlü Ç, Varcoe RL, Ferraresi R, Kum S. Midterm outcomes of
percutaneous deep venous arterialization with a dedicated system
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Robotics andEndovascular Surgery:
https://t.me/medicina_free
Current Status
LucindaCruddas, GuyMartin, andCeliaRiga
13
Introduction
Cardiovascular disease is a major cause of morbidity and
mortality in the Western world, and was responsible for 17.9
million deaths in 2016 [1]. The disease primarily affects coronary and peripheral blood vessels, and may result in a wide
spectrum of complications including myocardial infarction,
stroke, limb loss and ultimately death. Minimally invasive
interventional techniques have revolutionised the management of cardiovascular disease, and have a wide and varied
use across all aspects of disease treatment including ablative
techniques for the treatment of arrhythmias, stroke intervention with mechanical thrombectomy, aneurysms with stenting, and peripheral arterial disease with a range of
revascularisation technologies.
In minimally invasive endovascular surgery, percutaneous
access is established to guide catheters and guidewires
through vessels in the cardiovascular system. Fluoroscopy
enables real-time visualisation of catheters and guidewires
for safe manipulation and therapeutic action. Stenosis of cardiac and peripheral arteries can be treated with an inatable
balloon and expandable stents. Aneurysms are treated with
stent grafts which relieve pressure from the fragile aneurysmal vessel wall. In cardiac physiology, ablation catheters
apply ultrasound or radiofrequency energy to ablate tissue
responsible for arrhythmias. Endovascular surgery requires
precision and stability. The operator is guided by 2D uoroscopic images, and axial force and torque delivered at the
proximal end of catheters and guidewires. Force and haptic
feedback to the operator is limited. Vessel anatomy and catheter manoeuvrability also present challenges in navigating
anatomy and stability and reaching target sites. These challenges may be overcome by the advent of robotic technolo-
L. Cruddas · G. Martin · C. Riga (*)
Imperial Vascular Unit, Imperial College Healthcare NHS Trust, St
Mary’s Hospital, London, UK
e-mail: lucinda.cruddas@nhs.net; guy.martin@nhs.net;
c.riga@imperial.ac.uk
gies which aim to provide stability and precision and reduce
tremor and human error.
Robotic endovascular surgery and associated technologies
are the logical next stage of endovascular development and
have been at the forefront of surgical innovation over the past
few decades. The rst robotic system was the Da Vinci,
approved in 2000 by the Food and Drug Administration
(FDA). The Da Vinci is licensed for use in general laparoscopic, urological, thoracoscopic and thoracoscopically
assisted procedures. Laparoscopic robotic surgery has
upscaled exponentially, with multiple systems available,
which are employed internationally. Robot-assisted laparoscopic prostatectomy has achieved parity with standard laparoscopic techniques [2], and in 2020 approximately 1,243,000
laparoscopic robotic procedures were performed [3].
Robotic systems in endovascular surgery remain in development, but have the potential to continue to revolutionise
treatment of aneurysmal and occlusive disease. Robotic
endovascular technologies use steerable catheters which are
currently in use with endovascular intervention, but with
remotely controlled navigation systems. Additionally, 3D
projection of endovascular technologies has been a focus of
further development. Endovascular robotics remains in early
stages compared with laparoscopic robotics due to the
younger endovascular technologies which continue to be
rened, in parallel with robotic innovations. The advent of
steerable catheters was an early foundation for endovascular
robotics. They were designed to overcome the challenges in
navigating vascular anatomy, which continues to drive endovascular and robotic innovations. Robotic platforms enable
rotation in 30-degree increments and axial movement in
single- millimetre increments to enable greater stability, precision and navigation [3].
This chapter will review existing endovascular technologies including steerable catheters. Robotic technologies will
be examined, including approved technologies and those still
in development. The challenges of current designs and further developments will also be explored in order to provide
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
G. Geroulakos et al. (eds.), Mastering Endovascular Techniques, https://doi.org/10.1007/978-3-031-42735-0_13
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L. Cruddas et al.
research, development and clinical priorities to further translate and scale robotic technologies into routine surgical
practice.
Endovascular Surgery
Endovascular techniques are used in the treatment of aneurysmal disease; cardiac arrhythmias; coronary and peripheral
vascular stenosis due to atheromatous disease or dissection;
and thrombectomy in stroke. Minimally invasive
endovascular surgery has many potential benets compared
to open techniques, including fewer wound complications,
less post- operative pain, faster recovery and reduced hospital
stay length [4, 5]. Cardiac and respiratory complications
may be reduced, and mortality rates may be lower [6].
Minimally invasive technology may also enable the treatment of patients who are not t for a more substantial open
procedure, or in whom there is no technical option for open
repair. Endovascular techniques still face a number of challenges, however. In order to manipulate catheters and guidewires to distant targets, operators are dependent on visual
cues from 2D uoroscopy and haptic feedback. Navigation
of anatomy can be challenging especially in tortuous and
angulated vessels. Large doses of contrast agent may be
required, which can result in nephrotoxicity. Contact between
guidewires and catheters with the vessel wall can cause complications including dissection, embolisation, perforation
and thrombosis. Additionally, even with the use of lead
aprons, the operator is exposed to signicant radiation,
which may be associated with an increased incidence of
occupational cancers and cataracts [7]. Lead aprons and prolonged standing can also cause orthopaedic complications
for the operator. These challenges have driven the need for
further innovation in order to improve the safety, outcomes
and applicability of minimally invasive techniques.
Innovation in endovascular surgery has been achieved by
advancement in catheter design. Safe catheterisation requires
stability and manoeuvrability. Key trends in the advancement of catheter technology include the development of controlled steerable tips and the incorporation of haptic feedback.
These innovations have also been supported by signicant
developments in supporting wire technology, with a wide
range of disease- or technique-specic wires now widely
available. Intravascular devices are also an area of development. Complex aneurysmal disease and dissection can be
treated by complex stent grafts which include branched,
fenestrated and custom-made designs. Additionally, arterial
calcied plaques can be treated with drug-coated balloons to
reduce the risk of restenosis, or with atherectomy to remove
calcied, brotic tissue. Intra-arterial lithotripsy can be
employed in calcied coronary arteries prior to stent deployment during percutaneous coronary intervention.
Surgeon skills must develop in parallel to new technologies. Endovascular training requires standardised assessment
to ensure safe employment of new technologies and prociency in complex endovascular procedures. Advances in
technology have been accompanied by developments in virtual reality which can provide objective performance
feedback.
Steerable Catheters
Steerable catheters are the foundation for endovascular
robotic technologies. They were developed to overcome the
challenges of conventional catheters and are widely used.
Steerable technologies enable the operator to vary the shape
of the catheter distally. This provides a greater degree of control over direction of motion, and subsequent improved navigation of anatomy [8]. Steerable catheters are categorised
according to their actuation mechanism and can be either
magnetically or actively driven. Active devices include:
hydraulically driven, pull wire and smart-material actuated
[8]. Magnetic catheters and guidewires have a magnetic tip
which can be deected by a surrounding magnetic eld, generated by a large permanent magnet within the operating
room. Magnetic catheters have a soft tip which is safe within
vessel walls. They are, however, expensive to install and
maintain [9]. Pull wire catheters exist in multiple commercial forms and are commonly used in cardiac ablation and
mapping. They use actuator tendon control handles, attached
to an elastic nitinol catheter [10]. Commercially available
steerable catheters which have been integrated with robotic
technology include: Polaris XTM Steerable Diagnostic
Catheters (Boston Scientic Inc., Marlborough, USA) and
Artisan Extend Control Catheters (Hansen Medical Inc.,
Mountain View, USA) [11].
Hydraulic and smart-material technologies have not
become commercial technologies. Hydraulic pressure-driven
catheter technologies work by injecting a solution into
hydraulic bellow segments, to create variations in pressure.
Pressure changes modify the length of the bellows, bending
them in a single plane and steering the distal catheter tip [11].
Challenges in controlling the continuous bending of individual segments have meant that hydraulically driven catheters
are not a mainstream technology [9]. Smart- material actuated
catheters use variations in temperature to deect a shape
memory alloy (SMA) to guide the catheter tip [12]. However,
this technology carries the risk of overheating.
Force and pressure on catheter tips must be monitored and
fed back to the operator to prevent procedure complications
and ensure technical success. This is particularly relevant in
cardiac ablation and for ination pressure of balloon catheters [13]. Fibre optic-based sensors are commercially available for cardiac procedures but not for alternative
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interventions [14, 15]. The TactiCath catheter (Endosense
SA, Geneva, Switzerland) is an example of one of the main
commercially available ablation catheters with optical bres
in the distal end to measure magnitude and force applied at
the catheter tip [16].
Manual steerable catheters are a safe, established technology and used across a range of endovascular procedures [17,
18]. They are considered superior to conventional xed
catheters as their exibility enables navigation of challenging anatomy, greater precision and reduced catheter changes.
This results in greater technical success. Patient and operator
safety is also improved by the reduced need for contrast and
radiation. There is a reduced dependence on operator skill
and a atter learning curve [8]. Limitations of steerable catheters include: unpredictable friction; short shafts; large
diameters; low torsion; coupled tip and shaft movements;
costs; and limited compatibility with adjunct technologies
[19]. Robotically remote-controlled catheters have been the
next stage in steerable catheter development, in order to further improve steerability, precision and stability.
Remote-Controlled Catheter Navigation
Systems
Remote-controlled endovascular navigation systems are
available commercially. These technologies include electromechanically actuated platforms: Sensei robotic navigation
system (previously Auris Surgical Robotics, San Carlos CA,
now acquired by Johnson & Johnson, New Brunswick, New
Jersey), Magellan robotic catheter system (previously Auris
Surgical Robotics, San Carlos, CA, now acquired by Johnson
& Johnson, New Brunswick, New Jersey), CorPath vascular
robotic system (Corindus Vascular Robotics, MA, USA) and
Amigo remote catheter system (Catheter Precision Inc., NJ,
USA). A magnetically controlled robotic system is also commercially available: Niobe magnetic navigation system
(MNS; stereotaxis USA). Sensei and Magellan (Johnson &
Johnson, New Brunswick, New Jersey) are currently the
main commercial platforms in clinical practice and have
been acquired by Auris Health Inc. (Redwood City, CA,
USA).
Sensei/Magellan Robotic System
The Sensei robotic catheter was approved by the FDA in
2007 for cardiac mapping and ablation, and is now also in
use for both standard and complex endovascular aortic aneurysm repair (EVAR) [20–23]. A steerable guide catheter is
controlled by instruction from a “master-slave” remote
workstation. Steerable catheters are inserted into a custom-
designed sheath, the Artisan Extend Control Catheter, which
is manipulated via the remote control of a 3-dimesion of
freedom (3-DoF) joystick [24–26]. Any cardiac or mapping
catheter can be accommodated in the custom-steerable
sheath. The CoHesion visualisation module enables a visual
display of forces and tactile feedback by vibration of the
motion controller using 3D electroanatomic mapping Ensite
(St Jude Medical, MN, USA) and a distal force measurement
system, IntelliSense [9]. The sheath rigidity may, however,
increase the risk of mechanical complications [27]. A rigid
sheath can cause increased vessel wall trauma and may be
associated with bleeding, haematoma, dissection, pseudo
aneurysm, vessel rupture and thromboembolism.
The Magellan robotic system succeeded Sensei and
received FDA approval in 2012 (Fig. 13.1a, b, c) [20].
Similar to the Sensei robotic catheter, the Magellan has a
robotic arm which controls a steerable catheter. The catheter
has an inner leader and an outer sheath, controlled by pull
wires via a remote operator, with a 7-DoF joystick or navigation buttons. Catheter insertion, withdrawal, movement,
rotation and angulation are controlled remotely [24]. The
Magellan robotic system is associated with greater stability,
fewer catheter tip movements, greater steerability and greater
manoeuvrability than with conventional techniques [24, 26].
Robotic cannulation of peripheral vessels is faster compared
to manual cannulation, although it lacks force sensing and
feedback. Disadvantages also include the dependence on
custom single-use 14F sheaths and long set-up times [24].
Robotic set-up times are up to 15min, whilst conventional
set-up times are negligible. The aim is for faster target vessel
cannulation to offset longer set-up times. Faster procedure
times and increased accuracy could also offset extra costs.
Production of the Magellan robotic system was stopped in
2016 [9].
Amigo System (Catheter Robotics Inc. NJ, USA)
The Amigo system (Catheter Robotics Inc. NJ, UDS) is an
FDA-approved remotely controlled electromechanical
robotic system (Figs.13.2 and 13.3). Its intended use is for
cardiac mapping and radiofrequency ablation. A robotic arm
is attached to a standard electrophysiology table and used to
control standard commercially available steerable catheters
with 3-DoF (rotation, tip deection, insertion/withdrawal).
Linear motion, deection and rotation can be produced [27].
The Amigo system has been shown to be associated with
less operator radiation exposure than conventional techniques. Patient outcomes are comparable to manual techniques. Contact force is integrated, with a manual override
system [30]. The Amigo is, however, large and unwieldly
[27, 30–32].
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a b
L. Cruddas et al.
c
Fig. 13.1 The Magellan robot. (a) Magellan robot user interface. (b) Magellan robotic arm. (c) Magellan steerable catheter
electromechanical technology for remote control of standard catheters, guidewires and balloon/stent catheters, and
is compatible with angioplasty balloons and stent delivery
systems [33]. The CorPath 200 has a bedside robotic unit
with a single-use cassette on a robotic drive and an articulating arm. Standard guidewires and catheters can be moved
and exchanged with proximal force sensing, and are controlled by touch screen and joystick controls in a remote
workstation. The catheter can be advanced in 1mm increments, and rotated in 30-degree increments. The physician
must, however, manually perform initial catheter placement,
and guide and deploy devices [32]. CorPath 200 is associated with greater technical success and subsequent faster
procedure times and less uoroscopy use [34]. There are
Fig. 13.2 Amigo [28]
currently no large studies to assess the use of CorPath GRX,
however [31].
CorPath (Corindus Vascular Robotics, MA, USA)
Magnetic Robotic Navigation Systems: Niobe
The CorPath 200 system received FDA approval in 2012 for
remote-controlled stenting and ballooning in coronary interventions (Fig. 13.3). It was succeeded by CorPath GRX,
which received FDA approval for PCI and peripheral arterial intervention in 2016 and 2018 respectively [9]. It uses
(Stereotaxis, St. Louis, MO)
Magnetic technology can be used to remotely control catheters. In the Niobe system, two external magnets are placed
on either side of the patient to create a magnetic eld
13 Robotics andEndovascular Surgery: Current Status
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Fig. 13.3 CorPath [29]
Fig. 13.4 Niobe [35]
(Fig. 13.4). Bespoke catheters and guidewires with magnetic tips are controlled by the external magnets which vary
their intensity and position to deect the catheter tip with
3-DoF [36]. External magnet orientation is controlled
remotely via a mouse and joystick, and catheters are
advanced by a mechanical motor drive. The Niobe system
has been used in cardiac mapping and ablation, and peripheral arterial intervention [9, 32]. Magnetic catheters are less
stiff than electromechanical catheters and therefore may be
associated with a lower risk of vessel wall injury and perforation [9, 27]. However, the system requires a dedicated
room and magnetically compatible equipment. It is also
incompatible with real-time MRI [31].
The Catheter Guidance Control and Imaging (CGCI)
system (Magnetecs Inc., CA, USA) is currently in development for therapeutic interventions in cardiology, neurology
and obstetrics and gynaecology [37]. It uses eight electromagnets in a semi-circle conguration to manipulate a
magnetic eld and steer a magnetised catheter (Maxwell
mapping catheter) [9]. The magnetic eld can manipulate
instantaneous real- time catheter movements, which are precise, rapid and stable. Control is either by manual or automatic control mode. The CGCI system integrates
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uoroscopy, intracardiac echocardiac images, a multichannel ECG recording system and real-time mapping into a
single 3D display for visualisation of anatomy and equipment location. The catheter tip possesses tissue-contact
sensing lters to guide catheter movement. The operator
benets from real-time 3D visual feedback, and both operator and patient benet from reduced uoroscopic exposure,
faster procedure times, reduced training times and higher
success rates [37].
Initial data from robotic endovascular technologies is
promising. Compared with conventional methods, robotic
procedures are associated with greater stability and catheter
control. Procedure times are shorter and uoroscopy exposure is subsequently less. Costs are higher, but there is the
potential to offset these costs with faster procedure times and
fewer complications. Limitations include: lack of haptic
feedback; lack of compatibility with all conventional materials; and need for manual deployment of devices. These limitations have provided the foundations for further
developments.
Current Experiences inRobotic Endovascular
Surgery
Aortic Arch Cannulation
Robotic cannulation of the aortic arch in thoracic endovascular aortic repair (TEVAR) has been demonstrated to be safe
and effective in patients [38]. Eleven patients underwent
robotic and manual cannulation of the aortic arch, and
robotic cannulation was associated with signicantly fewer
high-intensity transient signals, detected by intraoperative
transcranial Doppler (TCS), compared to manual techniques.
This demonstrated that improved manoeuvrability, stability
and control associated with the robotic system could result in
less cerebral embolisation during TEVAR.
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Visceral Artery Cannulation
The Magellan robotic system was used to perform a fenestrated endovascular aneurysm repair (FEVAR) for an asymptomatic 73mm juxtarenal abdominal aortic aneurysm using
the Anaconda device (Vascutek, Inchinnan, United Kingdom)
with three customised fenestrations [39]. The left renal artery
was targeted robotically, whilst the two right renal vessels
were cannulated manually. The heavily calcied left renal
artery was successfully cannulated robotically, taking only
3min, with an additional 2min for guidewire exchange. This
was faster than the manual cannulation of the right renal
arteries (48min for both arteries). Magellan set-up time was
5 min. This case study demonstrates the effectiveness and
feasibility of the Magellan robotic system with accuracy and
reduced radiation as notable benets. Figure 13.5 demonstrates intraoperative robotic sheath and catheter positioning,
whilst Fig. 13.6 demonstrates real-time master–robotic
interface.
a
b
Robotic cannulation of renal and visceral target vessels
has been demonstrated in a number of patients undergoing
complex endovascular aortic procedures including fenestrated, branched and chimney stents [40] (Fig.13.7). Robotic
Fig. 13.6 Magellan user interface performing robotic cannulation of
the left renal artery in fenestrated endovascular aneurysm repair
c
Fig. 13.5 (a) Aneurysm with anaconda main body under angiography. (b) Robotic cannulation of the left renal artery. (c) Magellan sheath
positioning
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