Letter: Robotic-Assisted Neuroendovascular Intervention: Great Potential and Halted Expansion

Abstract

To the Editor: More and more studies imply the ongoing changes in the field of neuroradiology and management of stroke. Robotic neurovascular procedures were first reported in 2007 by Dabus et al.1 These modalities were first designed for cardiac and peripheral vascular settings. However, some recent case series reported its applicability in interventional neuroradiology with favorable outcomes similar to the conventional modalities.2 However, there are certain considerations to validating this technique in this field. There are various drawbacks to using robotic interventional neuroradiological approaches in the current literature. Although robotically assisted modalities are originally designated to enhance the efficacy of treatment and reduce the procedural time, it has been shown that robotic interventional neuroradiological modalities are associated with prolonged procedural time.3 However, it is still controversial whether this drawback is related to the clinician's experience or might be relevant to the structure and composition of the current modalities. Currently, there is no evidence regarding whether providing more training to physicians (to have more acquisition over using these interventions) would enhance the efficacy and shorten the procedural time. Therefore, it is logical that these approaches should not be used in critical settings and high-risk patients who need further interventions until further validation has been made. Accordingly, future investigations are aimed to standardize the experience of their included operators before assessing this outcome for an enhanced validation.4 It should also be noted that there are other drawbacks to be considered, being related to the technique regardless of the operator's experience. As robotic interventional modalities were initially developed to perform robotic percutaneous coronary interventions, evidence indicates many limitations to the developed neuroradiological ones. Therefore, many adaptations should be made to these modalities before being used in the relevant clinical settings. In 2018, the Food and Drug Administration cleared the second-generation CorPath GRX as an efficacious robotically assisted peripheral vascular intervention. However, there are many limitations to be considered to this modality. For instance, the current working length is 20 cm while it has been suggested that an optimal length of 40 cm would be more appropriate for neuroradiological applications. Moreover, the size, shape, and stiffness of used catheters also represent further limitations that should be addressed, being more unfavorable than conventional ones. In addition, the arm of the current CorPath GRX also has a limited range of movement. Furthermore, the disposable cassette of the CorPath GRX cannot be used to fit side-port catheters (including balloon-guided) properly. This approach has been reported to remarkably enhance catheterization for tortious neurovasculature. However, it still needs manual assistance and cannot manipulate over-the-wire devices. Besides, it has been shown that with many neurovascular events, implementing the triaxial approach of guiding catheter, microcatheter, and distal access catheter is not feasible with these modalities. Accordingly, overcoming these limitations might significantly enhance the efficacy of robotic interventional neuroradiology in future settings. Furthermore, in cardiac settings, a previous in vivo study reported that using artificial intelligence might favor the outcomes of robot-based interventions and reduce the risk of tissue manipulation and damage. This might suggest the application of such approaches in interventional neuroradiology to overcome the potential limitations and enhance the efficacy of therapy. Another limitation is the availability of these modalities because they are not widely used and not affordable in different settings. This might also limit the ability to conduct relevant investigations based on the complications above because the approach does not have significance over the conventional methods according to the current evidence. Finally, the setting-up for robotic interventions is different from the conventional method because the former requires the integration of two operator teams. Although robotic-based interventions show promising outcomes and easy-to-use practices, additional time is still needed to validate these approaches in different settings further to accommodate these approaches better based on the health status of patients and available resources. Future explorations should also include the addition of feedback and force-sensing technologies together with further automation for the navigational system.5