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Purpose: Our purpose was to study the accuracy of dynamic computed tomography angiography (d-CTA) in characterizing endoleak type, inflow vessels as compared with digital subtraction angiography (DSA) using qualitative and quantitative analysis. Methods: Between March 2019 and January 2021, all patients who underwent d-CTA imaging after EVAR were retrospectively reviewed. Two blinded independent reviewers qualitatively reviewed d-CTA and DSA images. Quantitative region of interest (ROI) analysis was performed by measuring time-resolved contrast enhancement within the aorta and endoleak lesion(s) in the aneurysm sac. Differences between time-to-peak enhancement (Δ TTP) across different ROIs were quantified. Results: A total of 48 patients underwent d-CTA during the study period, of whom 24 patients had abdominal EVAR and DSA imaging for comparison. Qualitative review of DSA imaging showed type I (n=4), type II (n=16), and type III (n=2) and no endoleak (n=2). In 23 of 24 patients (95.8%), d-CTA findings correlated with DSA findings for endoleak type. One patient had a type III endoleak that was demonstrated only in d-CTA (arising from defect in polymer sealing ring of Ovation stent graft) imaging. In type II endoleak cases, d-CTA identified more inflow vessels than DSA imaging (33 vs 21 vessels, p=0.010). Quantitative analysis showed mean (±SD) Δ TTP values for type I endoleak as 1.8 (±1.8) seconds, type II as 9.6 (±3.5) seconds, and for type III endoleak as 5.6 (±1.3) seconds. Conclusion: Dynamic CTA can accurately characterize aortic endoleak type, inflow vessels as compared with DSA imaging. Quantitative parameters such as Δ TTP enhancement can help better differentiate endoleak types and provide an objective approach to endoleak diagnosis.

Intraoperative transcranial Doppler (TCD) monitoring allows us to see intracranial blood flow changes related to endovascular and surgical manipulation in real time. This study evaluates the results of TCD monitoring during transcarotid artery revascularization (TCAR) with flow reversal, carotid endarterectomy (CEA) without shunt, with a shunt (shCEA), and transfemoral carotid artery stenting (tfCAS) with distal filter protection. Patients who underwent carotid artery revascularization with TCD monitoring were included. Patient demographics and medical history were recorded based on medical documentation. Intraoperative TCD, hemodynamics, fluoroscopy images, and surgical manipulation were recorded simultaneously with a 4-channel video recording system, and based on the recordings, the number of high-intensity signals (HITS) and middle cerebral artery (MCA) flow changes were registered. HITS during contrast injections were not included in the analysis due to the high number of artifacts. HITS were compared between the four groups, and HITS during lesion crossing/predilation/stent deployment/postdilation were compared between the tfCAS and TCAR groups. Thirty six patients were involved (mean age 69.5 ± 10.59 years; 24 male) (9 CEA; 11 shCEA; 4 tfCAS; 12 TCAR). Hypertension, diabetes mellitus, coronary artery disease, and smoking were frequent in all groups. Median number of HITS for CEA, shCEA, tfCAS, and TCAR were 5 (range: 0-90), 10 (range: 3-72), 197.5 (range: 153-340), and 29 (range: 2-74), respectively. The number of HITS during TCAR was not significantly different compared to CEA or shCEA but significantly lower than in patients receiving tfCAS ( P < .01). Procedural phases of lesion crossing, predilation, stent deployment, and postdilation were associated with significantly higher HITS during tfCAS than TCAR ( P = .002, P = .006, P = .04, P = .006, respectively). The number of embolic events during TCAR is comparable with CEA with and without a shunt and associated with a significantly lower HITS rate than tfCAS with distal filter protection. According to our results, TCAR appears to be a safer alternative to tfCAS.

Robotic-assisted endovascular therapy is a novel approach to augment precise skill requirements while simultaneously reducing radiation exposure. The CorPath system enhances the scope of minimally invasive procedures and facilitates the interventionalists to perform procedures in the field of vascular surgery, neurosurgery and interventional cardiology. The reason for increasing interest in the CorPath system is the ability to control these robots through wireless connection, raising the possibility for remote interventions. CorPath is currently the only commercially available endovascular robotic system. Robotic-assisted approach has a high technical success rate in the field of peripheral vascular and coronary interventions and has encouraging results regarding neurointerventions. Remote endovascular procedures may transform the future of stroke treatment in areas where distance-related time loss can affect procedural outcome.

Background Robotic-assisted endovascular surgery enables us to perform interventions from long distances. This study evaluates the workflow and telecommunication requirements of telerobotic peripheral vascular interventions. Methods Ten superficial femoral artery cases were performed by the operator being 44 miles away from the interventional suite, with an endovascular robotic system, on a high-fidelity endovascular simulator. Procedural success, technical success, fluoroscopy time, residual stenosis, contrast dose and network delay were registered. Communication success was assessed after each procedure on a scale from 1 (unacceptable) to 5 (ideal). Results Procedural success and technical success were 100% and 80%, respectively. The mean residual stenosis, fluoroscopy time and contrast dose were 1.7 ± 5.25%, 6.5 ± 1.8 min and 58.8 ± 14.8 ml. The mean network latency was 38.9 ± 3.5 ms. Median communication success scores were 4.5 (min: 4, max: 5) reported by both the operator and the bedside technician on a scale of 1 (unacceptable) to 5 (ideal). Conclusion With a stable network connection and good communication protocol, a high success rate was achieved for remote robotic-assisted peripheral vascular intervention in an ex vivo model.

Remote robotic-assisted endovascular interventions require real-time control of the robotic system to conduct precise device navigation. The delay (latency) between the input command and the catheter response can be affected by factors such as network speed and distance. This study evaluated the effect of network latency on robotic-assisted endovascular navigation in three vascular beds using in-vivo experimental model. Three operators performed femoral, carotid, and coronary endovascular robotic navigation blinded from the hybrid room with the prototype remote-enabled CorPath GRX system in a porcine model. Navigation was performed to different targets with randomly assigned network latencies from 0 to 1000 ms. Outcome measurements included navigation success, navigation time, perceived lag (1 = imperceptible, 5 = too long), and procedural impact scored by the operators (1 = no impact, 5 = unacceptable). Robotic-assisted remote endovascular navigation was successful in all 65 cases (9 femoral, 38 external carotid, 18 coronary). Guidewire times were not significantly different across the simulated network latency times. Compared to 0 ms added latency, both the procedural impact and perceived lag scores were significantly higher when the added latency was 400 ms or greater (

Endovascular surgery has become the standard of care to treat most vascular diseases using a minimally invasive approach. The CorPath system further enhances the potential and enables surgeons to perform robotic-assisted endovascular procedures in interventional cardiology, peripheral vascular surgery, and neurovascular surgery. With the introduction of this technique, the operator can perform multiple steps of endovascular interventions outside of the radiation field with high precision movements even from long-geographical distances.The first and second-generation CorPath systems are currently the only commercially available robotic devices for endovascular surgery. This review article discusses the clinical experiences and outcomes with the robot, the advanced navigational features, and the results with recent hardware and software modifications, which enables the use of the system for neurovascular interventions, and long-distance interventional procedures.A high procedural success was achieved with the CorPath robotic systems in coronary and peripheral interventions, and the device seems promising in neurovascular procedures. More experience is needed with robotic neurovascular interventions and with complex peripheral arterial cases. In the future, long-distance endovascular surgery can potentially transform the management and treatment of acute myocardial infarction and stroke, with making endovascular care more accessible for patients in remote areas.