Robot-assisted endovascular treatment of hepatic artery aneurysm: A case report

Case report

Incorporating new technologies into medical practice has allowed, in vascular surgery, the use of safer and less invasive techniques for treating complex conditions. In this context, robot-assisted endovascular surgery has emerged as a new alternative to interventional procedures, with its application expanding to peripheral and visceral approaches.

The objective of this paper is to describe the first case in the literature, to the best of our knowledge, of robot-assisted endovascular treatment in splanchnic arteries. Institutional review board approval was obtained (protocol: CAAE 73122923.1.0000.0071).

A 64-year-old asymptomatic, hypertensive, obese man presented to a vascular surgery outpatient clinic after an incidental finding of a hepatic artery aneurysm on abdominal ultrasound. On physical examination, no pulsatile masses were observed in the abdomen, and lower limb pulses were normal. Abdominal CT angiography revealed the presence of a saccular aneurysm of the proper hepatic artery measuring 3.7 × 2.7 cm and distant 0.6 cm from the origin of the gastroduodenal artery. An endovascular approach was proposed, and the robot-assisted technique was chosen.

The procedure was performed in a hemodynamic room with a fluoroscopy imaging device (Philips Medical Systems®, Wash, USA). The patient was under general anesthesia in the intraoperative period and under mechanical ventilation with orotracheal intubation. The robotic device used was the CorPath GRX platform (Corindus, Siemens, Massachusetts, USA), composed of a unit positioned next to the patient and a remote one controlled by the surgeon.

The unit near the patient comprises a single-use disposable cassette, to which the endovascular materials are attached, along with an articulated robotic arm (Figure 1(a)). In the remote unit (Figure 1(b)), the surgeon controls the movement of the endovascular devices with joysticks that allow fine movements for advancing, retreating, and rotating guidewires, catheters, and balloons. It can work with rapid exchange devices compatible with 0.014″ guidewires.OPEN IN VIEWER

A vascular surgeon in the operating room performed an ultrasound-guided puncture of the right common femoral artery with the progression of a 0.035″ hydrophilic guidewire, visualized through a fluoroscopic image, up to the thoracic aorta. Systemic heparinization with 5000 units of unfractionated heparin was performed. Then, an 8F short introducer was positioned, and a 5F RDC guiding catheter (Cordis, Florida, USA) was introduced for sequential selective catheterization of the celiac trunk and common hepatic artery ((Figure 2(a)).OPEN IN VIEWER

From this point on, the surgeon performed the procedure in the robot control room, with the assistance of a team in the operating room, for material exchange. Two 0.014″ ChoICE (Boston Scientific, Massachusetts, USA) guidewires were advanced through the robotic controls in parallel: the first one was placed inside the aneurysm sac, while the second one was placed in the proper hepatic artery distal to the aneurysm (Figure 2(b)).

Through the first guidewire, an Emerge balloon (Boston Scientific, Massachusetts, USA) was advanced, positioned distally to the aneurysm, and through the second one, a Renegade microcatheter (Boston Scientific, Massachusetts, USA) was advanced. The following steps were performed manually by the team in the operating room.

Three Packing coils (Penumbra, California, USA)—60 cm, 45 cm, and 30 cm—and 1 POD 60 cm coil (Penumbra, California, USA) were introduced through the microcatheter. Embolization was concluded with the injection of Onyx (Medtronic, Minnesota, USA) through the microcatheter (Figure 3(a)).OPEN IN VIEWER

Final angiography demonstrated aneurysm occlusion and sustained hepatic artery patency distally to the aneurysmal sac (Figure 3(b)).

The endovascular devices were removed uneventfully, and the puncture site was closed with a Perclose ProGlide hemostatic device (Abbott, Illinois, USA).

The patient was discharged from the hospital on 2nd postoperative day, asymptomatic. Control scan performed 120 days after embolization revealed treated aneurysm and preserved distal arterial flow.

Robot-assisted endovascular surgery has been used for navigation in brain territory, ¹ treating renal artery aneurysms, ² and embolizing uterine myomas. ³ Navigation has also been described at the level of aorta branches (superior mesenteric artery and celiac trunk) in the endovascular treatment of complex aortic aneurysms with branched and fenestrated grafts. ⁴ But there are no reports in the literature of robot-assisted treatment at the splanchnic territory.

The use of a robotic device allows for greater stability and precision in the movement of endovascular devices, reduces the radiation exposure of interventionists, and has a relatively fast learning curve. As a potential benefit, it may allow remote surgery in the future, bringing minimally invasive treatments to remote areas. The higher cost, lack of tactile feedback, and limited materials (only rapid exchange devices and 0.014 wires) still limit the expansion of this platform.

In conclusion, using a robotic platform for navigation in splanchnic territory is safe and effective.