Robotic percutaneous coronary intervention (PCI), available at WellSpan York Hospital, markedly reduces radiation exposure and physical strain for physicians, while promising improved outcomes by enhancing techniques with the possibility of remote procedures in the future.
WellSpan has a long history of providing advanced specialty care for complex medical conditions. Since PCI’s inception more than three decades ago, the health system has provided the procedure to patients throughout the region and beyond, notes William Nicholson, MD, Director of Interventional Cardiology. PCI has undergone tremendous advancements over the years, with the advent of drug-eluting stents and improved equipment and techniques.
“The complexity and possibilities have grown tremendously,” Dr. Nicholson says. “What can be done for patients with catheters and stents is now virtually limitless.”
In testament to that evolution, WellSpan York Hospital cardiologists perform 1,350 PCIs every year — many now via state-of-the-art robotic technology. Similar to other robotic procedures, robotic PCI allows the interventional cardiologist to perform the procedure while seated at a console instead of standing at the patient’s side. This enables the cardiologist to robotically guide wires, catheters and stents in a controlled fashion from the console cockpit.
WellSpan’s interventional cardiologists collaborate with the manufacturer, Corindus Vascular Robotics, to refine the device and its use. As such, WellSpan’s physicians are not only performing, but also creating and perfecting the cardiology procedures of the future. All WellSpan York Hospital interventional cardiologists perform robotic PCI, and WellSpan was the first Pennsylvania system to offer this approach.
“We have been on the forefront of the robotic experience for several years,” Dr. Nicholson says. “We adopted the first-generation robotic system over three years ago. Now, we have the new system. It has enhanced control and guidance, improved efficiency, and a more user-friendly interface.”
“The robot can perform highly controlled maneuvers and has the ability to replicate certain movements and techniques of a particular physician,” Dr. Nicholson says. The current wire manipulations being done with the robot by physicians at WellSpan York Hospital may one day be mimicked by the robot to enhance the skills and techniques of other physicians around the world. The ability of the physician to perform the procedure from across the room leads to the thought that an expert interventional cardiologist may eventually be able to contribute to, or perform, a complex procedure from an entirely different location in the world.
“We have been in consultation with Corindus regarding experimental plans and prototypes,” Dr. Nicholson says. “We gave advice on making the system more user-friendly for the practicing physician, and other significant iterations are yet to come. The catheterization lab 10 years into the future will be nothing like today’s, and the robot will play an integral role in that change.”
Expansive Benefits for Patients
Patient safety and procedural effectiveness are key considerations in robotic PCI, Dr. Nicholson says. One enhancement offered by the robotic approach is more precise stent selection. A July 2017 article in the Journal of the American Heart Association notes that stent selection is a “major modifiable risk factor for target vessel revascularization,” with stents that fail to cover the entire diseased area of the blood vessel being especially problematic. As a result, patients may need repeat procedures within a short time — less than a year in some cases. Robotic PCI relies less on the operator visually assessing the length of the diseased segment, but instead provides an automated, accurate measurement of the blocked artery, and therefore “has the potential to reduce the risk of in-stent restenosis and to improve patient outcomes,” the authors state.
William Nicholson, MD, Director of Interventional Cardiology at WellSpan, prepares to begin a robotic PCI procedure while seated at the console, without the need to wear a heavy lead-protective garment.
Robotic PCI also increases the likelihood that a radial, rather than femoral, approach may be used, Dr. Nicholson says.
“The radial artery approach is superior from a safety and bleeding-reduction perspective,” he says. “Yet, sometimes an interventionalist must use the leg for the case when the right radial artery is not adequate. It becomes difficult to lean across the patient and work on the left side, but the robot works equally well on the left or right side. That makes the radial approach available to more patients, who can then go home the same day.”
Radial-approach PCI has been found to have numerous safety benefits for ST-elevation myocardial infarction patients in particular. Advantages include reduced risk of death, stroke and major bleed. Patients may also prefer an approach they consider less invasive.
A 2014 study in the Journal of Invasive Cardiology found protective benefits for patients who underwent robotic rather than manual PCI, as well as benefits for physicians and staff involved in the procedure.
“Robotic PCI was associated with a reduced duration of fluoroscopy, less contrast media, and lower radiation exposure to the patient,” the authors wrote, adding, “Our analysis suggests robotic PCI offers radiation protection for both the physician and the patient.”
Potentially reduced risks to clinicians are wide-ranging, Dr. Nicholson notes.
“In the catheterization lab, we wear heavy lead aprons, which contribute to back problems in up to 80 percent of interventionalists,” he says. “There have also been increasing reports of left-sided brain cancer in interventional cardiologists.”
Studies of the robotic approach to PCI indicate the reduction in radiation exposure is dramatic. The remote console removes the physician from the radiation field, leading to a 95 percent lower rate of radiation exposure, as demonstrated in the PRECISE trial for the CorPath device.
“Robotic surgery gets us away from the table and from the radiation exposure,” Dr. Nicholson says.
Robotic PCI also allows interventionalists to adjust nimbly to changing circumstances. When a procedure cannot be completed robotically, Dr. Nicholson says, it is easy to transfer back to the physician completing the procedure at the table.
“It’s a smooth transition,” he says. “We don’t have to commit to one approach or another, and we can reconvert if we wish.”
Robotic PCI is among the factors that keep WellSpan on the leading edge of cardiac care.
“We are quite progressive and cutting edge in our offerings,” Dr. Nicholson says. “However, patients’ needs are always the first consideration in determining the best approach. While we employ the latest technology, we deploy it judiciously. We want to deliver the safest procedure to every patient, returning him or her home as swiftly as possible with the best outcome we can provide.”
To learn more about WellSpan Heart & Vascular, visit WellSpan.org/HV.