Robotic-Assisted Complex Coronary Intervention of Chronic Total Occlusion of Right Coronary Artery

The CorPath 200 robotic system remote-controlled robotic-enhanced device (Corindus) was developed to enhance percutaneous coronary intervention (PCI) procedural standardization and precision, and provide occupational hazard prevention for the interventional cardiologist. This device consists of a remote interventional cockpit and a bedside disposable cassette that enables the operator to advance, retract, and rotate guidewires and catheters. Robotic novel technology can be used to wire coronaries for PCI or pressure measurement, balloon/stent advancement and position, or in hybrid fashion, to complete a chronic total occlusion (CTO) intervention once crossed manually.

Case

A 62-year-old female presented to the hospital with chest pain. She had a history of hypertension, diabetes, obesity, and triple-vessel coronary artery disease (CAD). She was turned down for coronary artery bypass graft (CABG) surgery. The left anterior descending artery (LAD) and diagonal lesions were successfully treated with stents one month prior to the procedure below. A percutaneous intervention of her chronically occluded right coronary artery (RCA) was scheduled. 

The total occlusion in her proximal to mid RCA (Figure 1) was treated using a partial-robotic approach to reduce operator radiation exposure and enable precise stent placement. Right radial access was used for patient comfort and to decrease risk of access-site complications. A 6 French (Fr) sheathless Amplatz Left (AL)1 guide catheter was used to cannulate the RCA for additional support during the procedure. The vessel was wired and 99-100% of the lesion was crossed manually using a Pilot 50 guidewire (Abbott Vascular) and a 0.14 MicroCross catheter (Roxwood Medical). Intraluminal position was verified by injecting contrast through the MicroCross, after which the Pilot 50 was exchanged for an Iron Man guidewire (Abbott Vascular) and the catheter was removed. From this point forward, the physician was able to complete the intervention from the protection of the CorPath Interventional Cockpit. The guide catheter, guidewire, and 2.0 x 20 mm Trek balloon (Abbott Vascular) were loaded into the CorPath cassette. The balloon was advanced robotically and sequential pre-dilatations of the lesion were performed. The balloon was exchanged for a 3.25 x 38 mm drug-eluting stent (DES), which was robotically placed across the lesion and successfully deployed using the precision of the CorPath System. The stent delivery system was then exchanged for a 3.25 x 20 mm NC Trek (Abbott Vascular), advanced robotically, and post dilatations were performed. Final angiography demonstrated successful RCA revascularization (Figure 2). 

Discussion

In 2010-2011, Granada et al performed the first human successful robotic-assisted coronary intervention in 8 patients.¹ The reported technical success rate was 97.9%, with no device or procedure-related complications. Subsequently, the PRECISE (Percutaneous Robotically-Enhanced Coronary Intervention Study) enrolled a total of 164 patients at 9 centers. PRECISE demonstrated no major adverse cardiovascular outcome at 30 days (death, stroke, Q-wave myocardial infarction, or revascularization). The radiation exposure to the primary operator was 95.2% lower than the traditional method of PCI.²

Conclusion

A CTO case usually requires many wire exchanges (wire escalation, tip-shaping changes), and thus is typically performed via an over-the-wire system. Once the CTO lesion is crossed, various aspects of lesion preparation, stent placement, and post dilation can be performed with a hybrid approach using the robotic system. This case demonstrates the usefulness of CorPath System in the treatment of complex intervention. Along with radial access, it is beneficial for patients; CorPath makes it safer for operators along with augmenting our ability to deliver treatment with robotic precision.³ In this long, complex case, there was significant reduction in radiation exposure, as well as orthopedic strain, as the operator was permitted to sit in the comfort of a radiation-shielded cockpit.⁴ We believe the robotic systems are a great solution to the occupational challenges operators face every day in the lab.

References

1. Granada JF, Delgado JA, Uribe MP, Fernandez A, Blanco G, Leon MB, Weisz G. First-in-human evaluation of a novel robotic-assisted coronary angioplasty system. JACC Cardiovasc Interv. 2011 Apr; 4(4): 460-465. doi: 10.1016/j.jcin.2010.12.007.
2. Weisz G, Metzger DC, Caputo RP, Delgado JA, Marshall JJ, Vetrovec GW, et al. Safety and feasibility of robotic percutaneous coronary intervention: PRECISE (Percutaneous Robotically-Enhanced Coronary Intervention) Study. J Am Coll Cardiol. 2013 Apr 16; 61(15): 1596-1600. doi: 10.1016/j.jacc.2012.12.045.
3. Smilowitz NR, Moses JW, Sosa FA, Lerman B, Qureshi Y, Dalton KE, et al. Robotic-enhanced PCI compared to the traditional manual approach. J Invasive Cardiol. 2014 Jul; 26(7): 318-321.
4. Weisz G, Smilowitz NR, Metzger DC, Caputo R, Delgado J, Marshall JJ, et al. The association between experience and proficiency with robotic-enhanced coronary intervention-insights from the PRECISE multi-center study. Acute Card Care. 2014 Jun; 16(2): 37-40. doi: 10.3109/17482941.2014.889314. 

Disclosure: The authors report no conflicts of interest regarding the content herein.

The authors can be contacted via Dr. Kusum Lata at lata.drkusum@gmail.com