Several barriers need to be overcome to make “telestenting” feasible

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Ryan Madder

A robotic system for performing percutaneous coronary intervention (PCI) is now clinically available and is being used routinely to perform PCI at multiple centres in the USA. Associated with high procedural and technical success rates, robotic PCI dramatically reduces operator radiation exposure1 and may enable “telestenting”—allowing operators to perform PCI in a completely separate location from the patient. Ryan Madder reviews the feasibility of telestenting and the potential barriers that may prevent it from becoming a clinical reality.

Robotic PCI, using the CorPath GRX system (Corindus Vascular Robotics), is performed by a physician operator who manipulates the robotic controls (consisting of a series of joysticks and touchscreen buttons, while seated within a lead-lined cockpit). The robotic controls send electronic commands via a series of cables to a bedside robotic arm that is attached to the procedure table, thus facilitating the desired movements of the coronary guidewire, balloon catheter, stent catheter, and with the newest generation robotic system, the guide catheter as well.

Whereas the robotic cockpit and controls are typically positioned a few feet away from the patient in the corner of the procedure room, future advancements in robotic technology may facilitate the performance of robotic PCI over longer distances. The concept wherein a physician operator performs PCI on a patient in a separate physical location using robotics and telecommunications has been termed “telestenting”, the feasibility of which was recently tested in the REMOTE-PCI study, a small single-centre study performed at Spectrum Health in Grand Rapids, USA.2

In REMOTE-PCI, the physician operator, who was completely outside the procedure room that housed the patient, performed robotic PCI from behind the closed doors of an isolated separate room that had no direct line of audio or visual contact with those in the procedure room. The only means of communication between cath lab staff members and the physician operator was through use of telecommunications devices that allowed the operating physician to be “virtually present” in the procedure room. In this manner, 20 patients with a total of 22 target lesions underwent attempted telestenting. With an average procedural time of less than 30 minutes, 19 of 22 target lesions (86.4%) were successfully stented with this approach. Although the distance between the patient and operating physician in REMOTE-PCI was only approximately 55 feet, this study was the first to demonstrate that it is feasible for a physician to perform PCI from outside the confines of the procedure room by using a combination of robotics and telecommunications.

The REMOTE-PCI study represents a small initial step in the development of telestenting, which if developed further, may have several potential future applications. Over short distances, telestenting could be applied to completely eliminate physician radiation exposure during PCI by removing the physician entirely from the procedure room. Over long distances, telestenting may one day be applied to overcome geographic barriers to PCI, thereby improving access to PCI for patients in medically under-served regions of the world. In this regard, telestenting might allow high-volume operators who are experienced in performance of complex PCI to robotically assist less experienced operators, particularly when patient transfer to a high volume centre may not be feasible. Long distance telestenting could also be tested as an alternative to lytic therapy or inter-hospital transfer for primary PCI in patients with ST-segment elevation myocardial infarction.

These futuristic applications of telestenting, which may or may not be possible, will obviously require extensive research and resources to develop. To make telestenting over long distances possible, several barriers must be overcome, including the development of electronic connectivity between the robotic arm and robotic controls that will not require the current connectivity consisting of a series of cables. Once such connectivity is achieved, studies will be required to investigate whether current networks are capable of transmitting electronic signals with a lag time that is sufficiently minimal to ensure the safe performance of telestenting. Likewise, networks capable of rapid transmission of fluoroscopic and cineographic images with trivial lag time will be required.

Another barrier that must be overcome is the need for personnel at the patient’s bedside who are capable of obtaining arterial access, performing diagnostic angiography, and seating the guide catheter, all of which will be required prior to performing telestenting. Perhaps future robotic systems will eventually be developed to address some of these needs. Bedside personnel would also need to be capable of performing contrast injections, acquiring fluoroscopy and cineangiography images, and assisting with the management of PCI-related complications. In addition to these formidable barriers, it is anticipated that multiple other barriers, many of which may yet be unforeseen, will likely be encountered in further attempts to develop telestenting.

References

  1. Weisz G et al. J Am Coll Cardiol 2013; 61:159–600.
  2. Madder et al. EuroIntervention 2017;12: 1569–76.

Ryan Madder is at Frederik Meijer Heart & Vascular Institute, Spectrum Health, Grand Rapids, USA

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