Hybrid step-by-step approach to perform a Robotic DK Crush PCI

Supported by the EuroIntervention Journal

Authors

Arif A Khokhar^1,2, Aleksander Zelias³, Francesco Giannini⁴, Adriana Zlahoda-Huzior^2,5, Dariusz Dudek^4,6

Case summary

Robotic-assisted percutaneous coronary interventions (R-PCI) represent a new frontier for interventional cardiology¹. As device technology and operator experience evolve, R-PCI is increasingly being used to treat more complex lesions².

Bifurcation lesions requiring two-stent technique represent a challenge for current generation R-PCI devices due to the inability to actively control multiple wires and devices simultaneously.

To overcome this limitation, we describe our hybrid robotic and manual approach to perform a double-kissing (DK) crush procedure, using the second-generation CorPathGRX (Corindus, USA) R-PCI device.65-year-old male patient was staged for R-PCI of a Medina 1,1,1 distal left main lesion (Supplementary Video 1). Following manual cannulation with a 7Fr EBU 3.75 guiding catheter, the robotic cassette was connected with a coronary guidewire and a 3.5 x 15 mm non-compliant balloon loaded into the active wire, and device drives respectively.

An additional coronary guidewire and 3.5 x 15 mm balloon were parked in the passive drive (Figure 1). A pre-procedural plan was formulated in order to minimise the number of wire and device exchanges required within the robotic cassette. A hybrid strategy was adopted, combining robotic and manual control to perform the individual steps required for a DK crush PCI³ (Figure 2).

Side-branch interventions, re-crossing maneuvers and stent implantation were all performed under robotic control. Wire and balloon re-crossing was facilitated using the automation techniques (TechnIQ^TM) spin and dotter respectively. (Supplementary Videos 2 and 3).

Challenging side branch wiring, including re-crossing of stent struts, was achieved by using different combinations of the robotic wiring controls. These included joystick or 1 mm-touchscreen controls with or without the automation techniques. Use of the 1 mm touchscreen instead of joystick controls allowed for greater precision, as required during proximal cell re-wiring or balloon and stent positioning. (Figure 3)

Manual control was required for main-branch and kissing and proximal optimisation technique (POT) inflations due to the inability to actively control multiple wires and devices from the robotic console. Additionally, the resistance frequently encountered during bifurcation PCI, particularly when using multiple balloons and wires, could not be overcome robotically.

If the robotic system encounters resistance during device advancement a visual alert and alarm mechanism is triggered, which prevents further advancement of the device. 
→ This scenario was encountered when trying to advance a non-compliant 5.0. mm balloon for the final POT inflation and manual input was required to overcome the resistive forces.

A visual alert and alarm is triggered, which prevents further advancement of the balloon or stent and required manual intervention.
An optimal final angiographic result was achieved and confirmed by intravascular imaging (Figure 4), which did not reveal any complications. Total contrast volume was 150 mls, fluoroscopy time 35 minutes, and total radiation dose 1154 mGy. Our hybrid R-DKC procedure was possible due to the passive drive in the robotic cassette, which allows multiple wires and devices to be stored and manipulated (Figure 3).

Additionally, a device can be robotically advanced on a wire stored in the passive drive. By determining the optimal sequence of wire/device exchanges and communicating these steps in real-time to the catheter lab team using audio headsets, procedural time and efficiency can be improved.

In order to perform such hybrid procedures, two operators who are in direct communication with each other are required: a robotic operator and a manual operator who is also familiar with how to handle and exchange wires and devices within the robotic cassette.

Supplementary Material

References

1. Beyar R, Davies JE, Cook C, Dudek D, Cummins PA, Bruining N. Robotics, imaging, and artificial intelligence in the catheterisation laboratory. EuroIntervention. 2021;17:537–49.
2. Mahmud E, Naghi J, Ang L, Harrison J, Behnamfar O, Pourdjabbar A, Reeves R, Patel M. Demonstration of the Safety and Feasibility of Robotically Assisted Percutaneous Coronary Intervention in Complex Coronary Lesions: Results of the CORA-PCI Study (Complex Robotically Assisted Percutaneous Coronary Intervention). JACC Cardiovasc Interv. 2017;10:1320–7.
3. Hall AB, Chavez I, Garcia S, Gössl M, Poulose A, Sorajja P, Wang Y, Louvard Y, Chatzizisis YS, Banerjee S, Xenogiannis I, Burke MN, Brilakis ES. Double kissing crush bifurcation stenting: Step-by-step troubleshooting. EuroIntervention. 2021;17:E317–25.

Affiliations

1. Imperial College Healthcare NHS Trust, London, UK
2. Digital Innovations & Robotics Hub, Krakow, Poland
3. Center for Invasive Cardiology, Electrotherapy and Angiology in Nowy Sacz, Poland
4. Interventional cardiology unit, GVM Care & Research, Maria Cecilia Hospital, Cotignola, Italy
5. AGH University of Science and Technology, Department of Measurement and Electronics, Krakow, Poland
6. Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland