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Robotic-Assisted Endovascular Intervention
MarcusWong andGavinBritz
Introduction
The growth of robotics in neurosurgery has made its greatest
impact in functional and spine surgery. The introduction of robotic
assistance in the elds of interventional cardiology and vascular
surgery has paved the way for neurovascular robotics. Robotic
assistance holds the promise of increased navigation and device
precision, lower radiation exposure for the patient and primary
interventionalist, and future remote capabilities that will increase
health service access to patients around the country. In this chapter, we discuss the foundational work of the neurovascular robot,
its practical workow and advantages, its future potential, and
present limitations.
8
History
The rst published instance of robotic-assisted vascular intervention was performed in 2011 by Granada etal. who reported on
eight patients who underwent percutaneous coronary intervention
M. Wong · G. Britz (*)
Department of Neurosurgery, Houston Methodist Neurological Institute,
Houston, TX, USA
e-mail: gbritz@Houstonmethodist.org
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2025
E. Veznedaroglu (ed.), Advanced Technologies in Vascular
Neurosurgery, https://doi.org/10.1007/978-3-031-67492-1_8
135
136
M. Wong and G. Britz
[1]. In that series, there was a 97.9% success rate and a 97%
decrease in radiation exposure. These results were followed by
the Percutaneous Robotically Enhanced Coronary Intervention
(PRECISE) study and Complex Robotically Assisted Percutaneous
Coronary Intervention (CORA-PCI) study. They found a 97.5%
success rate and 95% decrease in radiation exposure in 164
patients requiring a single coronary stent and 91.7% technical and
99.1% clinical success rate in 334 PCIs performed by a single
operator, respectively [2, 3]. The success of these studies opened
the door for peripheral vascular work in the Robotic-Assisted
Peripheral Interventional (RAPID) trial for critical limb ischemia
and claudication of the femoropopliteal arteries. Here, the authors
demonstrated 100% technical success rate and shorter uoroscopy times in robotic-assisted interventions [4]. The robotic system used in this trial was the CorPath 200 by Corindus, and its
success secured FDA approval for its use in peripheral vascular
disease and PCI.
Robotic-Assisted Endovascular Work
On the heels of this success in the cardiac and vascular elds,
robotic assistance set its sights on neurointervention. There were
some gaps to bridge, however. In contrast to the aforementioned
elds, neurovascular intervention often requires a triaxial system
with need for microvascular support. Critically, the intracranial
space has very little margin for error, and small unintended movements of the microcatheter can lead to disastrous results. To
address these concerns, Britz etal. tested and suggested hardware
and software modications for the updated system, the CorPath
GRX.That group rst successfully used the robot invitro in an
aneurysm ow model to navigate a microcatheter, deploy and
bare metal stent, and deliver two coils (Fig. 8.1) [5]. These interventions were made possible by the addition of active device xation. This allows microcatheter movement without changing the
position of the guidewire, thereby reducing the risk of unintentional wire movement and reducing the risk of vessel perforation.
Further, the same group performed robotic navigation in extracranial carotid branches in a porcine model. These vessels are
8 Robotic-Assisted Endovascular Intervention
Fig. 8.1 Operational set up demonstrating remote control of endovascular
robot to navigate and coil a ow model
137
Fig. 8.2 Robotic navigation and coiling of porcine rete mirabile (blue)
bioequivalent in size to intracranial human arteries. These were
possible with the addition of a second Y adaptor to accommodate
and enable the use of the microcatheter [5]. These device modications and testing led to the CorPath GRX’s approval for the
European Conformity (CE) mark for neurovascular work. There
is still no FDA approval at this time.
The Britz group continued its work, demonstrating the feasibility of robotic-assisted AVM embolization via four rete mirabile
embolizations in a swine model (Fig. 8.2) [6]. Most recently, Britz
and Lumsden also performed a proof-of-concept study to perform
a carotid artery stent and mechanical thrombectomy in a
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M. Wong and G. Britz
fresh- frozen cadaver through a transcarotid artery approach
utilizing the TCAR system [7]. Carotid artery stenting has also
previously been performed in the discontinued Magellan robotic
system in 13 patients with 100% technical success and no neurologic adverse effects postoperatively [8].
The rst in-human intracranial work was performed in Canada
in 2020 to treat a basilar aneurysm via stent-assisted coiling [9].
Since then, six patients have undergone robotic-assisted embolization by the same group. Four of these were neck-bridging stents,
and two ow-diverting stents. These were performed with 100%
technical success without morbidity or mortality. At 1-year follow- up, four of the aneurysms were completely occluded, while
two had a residual neck [10]. Britz et al. reported the rst inhuman extracranial embolization series in six patients without any
complication [11]. In 2022, Tateshima etal. reported on the rst
case of robotic-assisted spinal angiography [11]. Here, the authors
manually performed the balloon angioplasty and deployment of
stents for carotid interventions. The CorPath GRX was able to
navigate the balloon and stent to the desired location, but there
was no robotic mechanism for their nal deployment. Sajja etal.
described their experience with ten carotid artery stenting procedures. The same group later compared the robotic-assisted transradial carotid stent to the manual transradial approach and found
that the robotic group took signicantly longer time and required
one conversion to transfemoral. There otherwise was 100% technical success rate without morbidity [12, 13].
CorPath GRX System
The CorPath GRX is the last version of the Corindus endovascular system. It includes an interventional cockpit, which is comprised of a radiation shield, console panel, and monitors, as well
as the bedside unit that can be mounted on the operating table.
The console panel has a touchscreen, a turbo button for faster tool
movement, and three joysticks, which are used to control the
guide catheter, guidewire, and interventional devices such as balloons or stents. The addition of the third joystick, a bedside touch-
ab
8 Robotic-Assisted Endovascular Intervention
139
screen, and active guide control, which enables the ability to
advance, retract, and rotate the guide catheter, separates the GRX
from the previous CorPath 200 version. The monitors display
essential angio suite views, such as the live uoroscopy images,
vital signs, and saved angiographic images. The bedside unit handles a exible robotic arm that is guided to an optimal position for
the access site. Importantly, there is a single-use cassette that
holds the guiding catheter, guidewire, and a stent or balloon catheter. The cassette also includes a support track that holds the
guiding catheter in place and prevents it from bending when the
catheter is advanced or retracted or during device exchanges
(Fig. 8.3).
In its present iteration, the system uses 5- to 7-Fr guide catheters, 0.014-in guidewires, and rapid-exchange (RX) or monorail
balloons and stents. These devices are manipulated by the joystick
and touchscreen in cockpit. Since the range of motion of the guide
catheter is only 20cm, the target lesion must be approached manually. Once in range, lesion measurement and device deployment
can be done robotically. The GRX model has several lesion crossing capabilities based on existing manual techniques. The spin
function rotates the wire clockwise and counterclockwise. The
rotate-on-retract is a 270-degree rotation of the wire achieved
upon retraction. The wiggle function causes the wire to oscillate,
to prevent prolapse in tortuous vessels. The dotter function moves
Fig. 8.3 (a): Workstation control, a1: touchscreen control, a2: joysticks, a3:
ultra-high-denition display monitor.(b): Table-siderobotic unit. b1: articulating arm, b2: robotic drive unit withcassette and guidecatheter in place, b3:
workstation. b4: in vitro ow model, cannulated with guided catheter
140
M. Wong and G. Britz
the wire rapidly back and forth while advancing the device which
helps cross calcied lesions.
Every generation of the Corindus system is compatible with
every angiogram suite and operating table. The drive is typically
draped and prepared for intervention in approximately 2minutes.
The system’s estimated cost is between $500,000 and $650,000,
not including further single-use cassettes and devices which are
approximately $300.
A primary advantage to a robotic system is the reduction of
occupational hazards for the interventionalist during the robotic
navigation. The technical revolution of endovascular surgery has
resulted in a high volume of uoroscopy-guided interventions,
which leads to higher cumulative radiation doses for interventionalists. This has increased occupational hazards such as cataracts
and left-sided neck and brain tumors [14, 15]. The journey to
reduce radiation exposure paradoxically has also increased the
incidence of chronic neck and spine injuries through the use of
heavy leaded aprons and neck collars. By removing the operator
from the direct vicinity of the radiation source, the operator can
assume a more ergonomic seated position without the burden of
the leaded aprons. Indeed, the RAPID II trial showed a 96.9%
radiation exposure reduction for the primary interventionalist.
With robotic navigational functions, there is increased technical accuracy, eliminating physiological tremors and operative
fatigue. By removing the typical movements of manual interventions, such as shaking of the hands, fast accelerations and decelerations of the devices, and unintentional wire movements or
rotations during manipulations or device exchanges. This extra
stability may contribute decreased technical errors and a decreased
complication rate of vessel injury, distal embolization, or stent
misplacement.
Telerobotic Intervention
We are on the cusp of witnessing a paradigm shift in neurovascular healthcare delivery. While not presently ready for prime time,
an exciting advantage of robotic-assisted neurointervention is its