The Rise of the Machines: Vascular Robotics and Guidance Systems

Efforts to develop robotically assisted laparoscopic techniques have had limited success, and some notable failures. At the same time, advances in robotic catheterization systems have spurred interest in their use during endovascular surgery. On Thursday afternoon, Dr. Hans Coveliers of VU Medical Center in Amsterdam, the Netherlands, will join other experts in reviewing the state of vascular robotics and future developments in the field.

Dr. Coveliers calls laparoscopic robotic aortic surgery “a failed experiment,” adding that robotically assisted laparoscopic repair of aortic aneurysms is no more effective than manual laparoscopic techniques. In one study, use of a robotic system cut down on suturing time during aortic anastomosis, but the complexity of the device significantly lengthened total operating times, and robotically treated patients fared no better than those who underwent a manual, fully laparoscopic approach.

Other vascular surgeons also have reported steep learning curves and longer operating times because of the intricacy of these devices, and these drawbacks have eroded their potential cost savings, according to health technology assessments.

Safety is also a concern. “In particular, robot-assisted laparoscopic surgery for aortic aneurysmal disease has shown some catastrophic cases,” Dr. Coveliers said. There have been reports of laparoscopic robotic aortic repairs that had to be converted because of bleeding from the anastomosis. And in a recent review of 12 years of safety reports from the Food and Drug Administration, LexisNexis, and PACER, investigators linked the controversial da Vinci robotic surgical system to 245 adverse events and 71 deaths.

“All cases that are suitable for robotic vascular surgery can be treated with simple endovascular techniques in a faster, safer, and thus better way,” Dr. Coveliers emphasized. As a result, vascular surgeons are shifting their focus from robot-aided arterial anastomosis to robotically assisted endoluminal vessel cannulation, he said. “This is more in line with the current developments in endovascular surgery, where advanced catheterization skills are required for vessel cannulation in cases of complex endovascular aneurysm repair,” he added.

Because robotic systems offer better steerability over manual tracking systems or conventional cannulation techniques, they can potentially simplify treatment of complex EVAR cases, according to Dr. Coveliers. Studies have reported that robotic endovascular surgery cut total procedure time by a factor of six, shaved about 12 minutes off fluoroscopic exposure time, and reduced the number of movements required in robotic surgery by up to 10 times. A review of these studies concluded that robotic endovascular systems offer better catheter stability, a shorter learning curve, and better performance while cannulating tortuous vessels, compared with conventional endovascular techniques.

But it remains unclear whether current robotic systems can consistently streamline EVARs and benefit patients. Studies of phantom and animal models have posted strong results, but more clinical trials in humans are needed, according to reviewers.

Earlier this year, for example, reviewers scrutinized 18 studies of four robotic navigation systems and concluded that only one system potentially outperformed manual cannulation during complex vascular cannulation tasks, and only when performed in a rigid experimental environment. Average tracking accuracy was 1 mm under those controlled conditions, but target registration error exceeded 3 mm when measured in a non-rigid environment. The reviewers concluded that it was unclear if current systems save time and materials while improving clinical outcomes in complex EVAR.

But such proof is just around the corner, according to Dr. Coveliers. “In the future,” he said, “manual steering of catheters and guide wires for cannulation of any target vessel will be obsolete, and will be replaced by robotic navigation systems that reduce fluoroscopy time, radiation dose and contrast volumes to a minimum.”

Session 53: Vascular Robotics and Guidance Systems

3:52 p.m. – 3:57 p.m.

Grand Ballroom East, 3rd Floor

Efforts to develop robotically assisted laparoscopic techniques have had limited success, and some notable failures. At the same time, advances in robotic catheterization systems have spurred interest in their use during endovascular surgery. On Thursday afternoon, Dr. Hans Coveliers of VU Medical Center in Amsterdam, the Netherlands, will join other experts in reviewing the state of vascular robotics and future developments in the field.

Dr. Coveliers calls laparoscopic robotic aortic surgery “a failed experiment,” adding that robotically assisted laparoscopic repair of aortic aneurysms is no more effective than manual laparoscopic techniques. In one study, use of a robotic system cut down on suturing time during aortic anastomosis, but the complexity of the device significantly lengthened total operating times, and robotically treated patients fared no better than those who underwent a manual, fully laparoscopic approach.

Other vascular surgeons also have reported steep learning curves and longer operating times because of the intricacy of these devices, and these drawbacks have eroded their potential cost savings, according to health technology assessments.

Safety is also a concern. “In particular, robot-assisted laparoscopic surgery for aortic aneurysmal disease has shown some catastrophic cases,” Dr. Coveliers said. There have been reports of laparoscopic robotic aortic repairs that had to be converted because of bleeding from the anastomosis. And in a recent review of 12 years of safety reports from the Food and Drug Administration, LexisNexis, and PACER, investigators linked the controversial da Vinci robotic surgical system to 245 adverse events and 71 deaths.

“All cases that are suitable for robotic vascular surgery can be treated with simple endovascular techniques in a faster, safer, and thus better way,” Dr. Coveliers emphasized. As a result, vascular surgeons are shifting their focus from robot-aided arterial anastomosis to robotically assisted endoluminal vessel cannulation, he said. “This is more in line with the current developments in endovascular surgery, where advanced catheterization skills are required for vessel cannulation in cases of complex endovascular aneurysm repair,” he added.

Because robotic systems offer better steerability over manual tracking systems or conventional cannulation techniques, they can potentially simplify treatment of complex EVAR cases, according to Dr. Coveliers. Studies have reported that robotic endovascular surgery cut total procedure time by a factor of six, shaved about 12 minutes off fluoroscopic exposure time, and reduced the number of movements required in robotic surgery by up to 10 times. A review of these studies concluded that robotic endovascular systems offer better catheter stability, a shorter learning curve, and better performance while cannulating tortuous vessels, compared with conventional endovascular techniques.

But it remains unclear whether current robotic systems can consistently streamline EVARs and benefit patients. Studies of phantom and animal models have posted strong results, but more clinical trials in humans are needed, according to reviewers.

Earlier this year, for example, reviewers scrutinized 18 studies of four robotic navigation systems and concluded that only one system potentially outperformed manual cannulation during complex vascular cannulation tasks, and only when performed in a rigid experimental environment. Average tracking accuracy was 1 mm under those controlled conditions, but target registration error exceeded 3 mm when measured in a non-rigid environment. The reviewers concluded that it was unclear if current systems save time and materials while improving clinical outcomes in complex EVAR.

But such proof is just around the corner, according to Dr. Coveliers. “In the future,” he said, “manual steering of catheters and guide wires for cannulation of any target vessel will be obsolete, and will be replaced by robotic navigation systems that reduce fluoroscopy time, radiation dose and contrast volumes to a minimum.”

Session 53: Vascular Robotics and Guidance Systems

3:52 p.m. – 3:57 p.m.

Grand Ballroom East, 3rd Floor

Efforts to develop robotically assisted laparoscopic techniques have had limited success, and some notable failures. At the same time, advances in robotic catheterization systems have spurred interest in their use during endovascular surgery. On Thursday afternoon, Dr. Hans Coveliers of VU Medical Center in Amsterdam, the Netherlands, will join other experts in reviewing the state of vascular robotics and future developments in the field.

Dr. Coveliers calls laparoscopic robotic aortic surgery “a failed experiment,” adding that robotically assisted laparoscopic repair of aortic aneurysms is no more effective than manual laparoscopic techniques. In one study, use of a robotic system cut down on suturing time during aortic anastomosis, but the complexity of the device significantly lengthened total operating times, and robotically treated patients fared no better than those who underwent a manual, fully laparoscopic approach.

Other vascular surgeons also have reported steep learning curves and longer operating times because of the intricacy of these devices, and these drawbacks have eroded their potential cost savings, according to health technology assessments.

Safety is also a concern. “In particular, robot-assisted laparoscopic surgery for aortic aneurysmal disease has shown some catastrophic cases,” Dr. Coveliers said. There have been reports of laparoscopic robotic aortic repairs that had to be converted because of bleeding from the anastomosis. And in a recent review of 12 years of safety reports from the Food and Drug Administration, LexisNexis, and PACER, investigators linked the controversial da Vinci robotic surgical system to 245 adverse events and 71 deaths.

“All cases that are suitable for robotic vascular surgery can be treated with simple endovascular techniques in a faster, safer, and thus better way,” Dr. Coveliers emphasized. As a result, vascular surgeons are shifting their focus from robot-aided arterial anastomosis to robotically assisted endoluminal vessel cannulation, he said. “This is more in line with the current developments in endovascular surgery, where advanced catheterization skills are required for vessel cannulation in cases of complex endovascular aneurysm repair,” he added.

Because robotic systems offer better steerability over manual tracking systems or conventional cannulation techniques, they can potentially simplify treatment of complex EVAR cases, according to Dr. Coveliers. Studies have reported that robotic endovascular surgery cut total procedure time by a factor of six, shaved about 12 minutes off fluoroscopic exposure time, and reduced the number of movements required in robotic surgery by up to 10 times. A review of these studies concluded that robotic endovascular systems offer better catheter stability, a shorter learning curve, and better performance while cannulating tortuous vessels, compared with conventional endovascular techniques.

But it remains unclear whether current robotic systems can consistently streamline EVARs and benefit patients. Studies of phantom and animal models have posted strong results, but more clinical trials in humans are needed, according to reviewers.

Earlier this year, for example, reviewers scrutinized 18 studies of four robotic navigation systems and concluded that only one system potentially outperformed manual cannulation during complex vascular cannulation tasks, and only when performed in a rigid experimental environment. Average tracking accuracy was 1 mm under those controlled conditions, but target registration error exceeded 3 mm when measured in a non-rigid environment. The reviewers concluded that it was unclear if current systems save time and materials while improving clinical outcomes in complex EVAR.

But such proof is just around the corner, according to Dr. Coveliers. “In the future,” he said, “manual steering of catheters and guide wires for cannulation of any target vessel will be obsolete, and will be replaced by robotic navigation systems that reduce fluoroscopy time, radiation dose and contrast volumes to a minimum.”

Session 53: Vascular Robotics and Guidance Systems

3:52 p.m. – 3:57 p.m.

Grand Ballroom East, 3rd Floor