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IntroductionRobotic percutaneous coronary intervention

(PCI) offers the benefits of precision, control, and safety. The specific advantages of reduced radiation exposure and improved ergonomics for the opera-tor are particularly impactful during long, difficult cases. This case study exemplifies the capabilities and success of robotic PCI in the treatment of com-plex lesions.

Case HistoryA 54-year-old man with a history of tobacco use

and a family history of premature coronary athero-sclerosis was admitted to the hospital with prolonged chest pain and dyspnea. He was diagnosed with a non-ST elevation myocardial infarction.

He was treated with aspirin, a beta blocker, a sta-tin, intravenous (IV) unfractionated heparin (UFH), and nitroglycerin. An echocardiogram showed nor-mal left ventricular function and wall motion with ejection fraction 55-60%.

Cardiac Catheterization ProcedureCardiac catheterization was performed using right

radial arterial access via 6 French (Fr) hydrophilic Glidesheath (Terumo). Coronary arteriography re-vealed a 95% stenosis in the proximal left anterior de-scending (LAD) artery with a rise to a medium-sized diagonal branch with a 75% ostial lesion (Figure 1). The decision was made to perform provisional bifur-cation stenting.

Interventional ProcedureThe CorPath Vascular Robotic System (Corindus

Vascular Robotics) was utilized for percutaneous cor-onary intervention. Robotic PCI has been described

in detail elsewhere.1 Briefly, the CorPath system con-sists of a bedrail-mounted robotic drive and sterile cassette. The cassette can be loaded with commer-cially available 0.014-inch guidewires and rapid ex-change angioplasty and stent delivery systems. The cassette manipulates the guidewires and angioplasty devices using motorized rollers that provide axial and rotational forces. The robotic drive is connected to the control console via a communication cable. Op-erators perform PCI seated in a radiation-shielded interventional cockpit in the catheterization labora-tory. Guidewires and catheters are manipulated using

CliniCal Case Update

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Provisional Bifurcation Stenting with Robotic PCI

Paul T. Campbell, MD, FSCAI, FACC; Katherine J. Tullis, RCIS; Brian J. McCartney, RN; Gina M. Harless, RN

Disclosure: The authors report no financial conflicts. This educational activity was sponsored by Corindus Medical.

Figure 1. LAD and diagonal branch pre-intervention.

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joysticks and a touch screen to control the move-ments of intravascular devices. Fluoroscopy, elec-trocardiography, and hemodynamics are “slaved” to monitors within the interventional cockpit for enhanced viewing.

The patient was consciously sedated and anti-coagulation was achieved using additional IV UFH with an activated clotting time of 250-300 seconds.

The left main was engaged with a Runway 6 Fr Left BU4 guide catheter with side holes (Boston Scientif-ic). A 0.014-inch Runthrough guidewire (Terumo) was loaded into the CorPath cassette by the scrub tech. The operator moved to the robotic interven-tional cockpit. Using the joystick on the control con-sole, the operator advanced the wire across the se-vere stenosis in the LAD. The wire was then placed

Figure 2. Angioplasty of ostium of diagonal branch.

Figure 4. Plaque shift into diagonal branch post-stent.

Figure 3. Stent placement in LAD.

Figure 5. Final angioplasty of diagonal branch through LAD stent.

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in the cassette parking track. A 0.014-inch BMW guidewire (Abbott Vascular) was loaded into the CorPath cassette drive unit and robotically crossed the diagonal branch stenosis.

Dilatation of the ostium of the diagonal branch was performed with a 2.5 mm x 12 mm Trek balloon (Abbott Vascular) placed robotically over the BMW guidewire (Figure 2). The guidewire was then pulled back into the guide catheter. A 3.25 mm x 18 mm Xience Alpine drug-eluting stent (Abbott Vascular) was then placed robotically over the Runthrough guidewire dilating the LAD (Figure 3). This resulted in plaque shift into the ostium of the diagonal branch (Figure 4). The Runthrough guidewire was then robotically partially retracted, and then advanced through a proximal stent strut to rewire the diago-nal branch ostium. A 2.5 x 12 mm Sprinter balloon (Medtronic) was driven robotically over the Run-through guidewire through the proximal stent strut to dilate the diagonal branch ostium (Figure 5). Final angiography demonstrated negligible residual steno-sis within the stented LAD and the angioplastied di-agonal (Figure 6). No dissection was visualized and

TIMI 3 flow was maintained. The patient tolerated the procedure well and was discharged to home the following day.

DiscussionRobotic PCI has emerged as a modality to assist

in treating coronary lesions, offering reduced radia-tion exposure, and improved ergonomics for the op-erator.1,2 Precise controlled movements of coronary guidewires, balloons and stents are important in ensuring the patient gets the right stent in the right place.3 Proficiency in the use of robotic PCI leads to its routine use in complex situations including ostial or bifurcation lesions, in-stent restenosis, tortuous vessels, and long lesions as well as vein grafts and through internal mammary grafts. Routine applica-tion of the CorPath Vascular Robotic System can be integrated into the interventional catheterization lab and with proper training and experience, the inter-ventionalist can add this new innovation to standard PCI care adopting a “robotics-first” approach.

The case described above shows the successful uti-lization of the CorPath Vascular Robotic System for bifurcation lesions. It demonstrates the capabilities of the technology including double wire intervention and the ability to recross through a stent strut for branch vessel ostium dilatation. More experience with this technology will potentially add to its utili-zation in more complex lesions.

References1. Weisz G, Metzger DC, Caputo RP, et al. Safety and

feasibility of robotic percutaneous coronary interven-tion: PRECISE (percutaneous robotically-enhanced coronary intervention) study. J Am Coll Cardiol. 2013;61(15):1596–1600.

2. Campbell P, Tennis P, Bitler C, et al. Staff exposure to radiation during percutaneous coronary inter-ventions: randomized comparison of robotic versus manual procedures. Catheter Cardiovasc Interv. 2016;87:S80–S81.

3. Campbell PT, Kruse KR, Kroll CR, Patterson JY, Esposito MJ. The impact of precise robotic lesion length measurement on stent length selection: ram-ifications for stent savings. Cardiovasc Revasc Med. 2015;16(6):348–350.

Figure 6. LAD diagonal branch post-PCI.

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