‘Telestenting’ an Early-Days but Enticing Idea for PCI’s Future

SAN DIEGO, CA—Many rural towns may not have easy access to an interventional cardiologist who can perform primary PCI, or to a nearby PCI-capable hospital, but using robotic methods to stent from afar may one day bridge that gap. New data released at TCT 2018 show the feasibility of doing procedures through an online network from over 100 miles away.

Investigator Ryan Madder, MD (Spectrum Health, Grand Rapids, MI), pointed out in his presentation that only 80% of US residents live within 60 minutes of PCI. In less populated states like Wyoming, the proportion drops to 31%.

Today’s robotic stenting involves the robot and controls connected though a cable, which the physician controls in the room. A previous preliminary study by Madder found that performing robotic PCI was possible from a separate room with a cable running between them.

“In the current robotic system, there is a series of cables that hardwire the robotic controls to the robotic arm,” Madder said in his presentation, “so obviously, the length of these cables is the limit that you can extend the distance from the patient or from the robotic arm. In the REMOTE-PCI study that we did, that distance was about 55 feet.”

To resolve some of the geographic disparities of PCI procedures, this “telestenting” needed to go online, Madder said. In late 2017, engineers developed a system that allowed physicians to control a robotic arm over a network connection, rather than through cables.

Madder and colleagues tested the feasibility of this model performing PCI procedures using a simulated catheter lab. In one experiment, the robotic controls were placed in a medical building 4.6 miles away from the simulator. A cardiology fellow and scrub tech obtained vascular access, guided the seated catheter, performed contrast injections, loaded devices onto the robotic arm, and performed balloon inflations, but all movement of the catheter was controlled by the robot with the controls at a distance.

The next step involved testing the system in a pig model. The team found they could successfully place a stent using this semi-offsite system, even from a distance of 103 miles.

Having shown that this technology is feasible at great distances, the larger challenge is now understanding more about the network connecting the controls to the machine, he said. Latency, or delay between information transfer, is important to consider, especially with high internet traffic.

Additionally, Madder says that one assistant will always need to be in the room, though he is not yet sure what level of training that person needs to have. “They need to be able to obtain vascular access and perform angiography. [And] you need someone there who can manage complications,” he said. “I think the lowest-hanging fruit for sites to potentially deploy this would be in labs where they have a cardiologist who is invasive but not interventional.”

Madder also wants to explore if this technique could be used in other vascular beds, like lower leg ischemia and acute stroke interventions.

While several more steps need to happen before clinical trials, Madder’s team is optimistic and continues to conduct more telestenting studies. “We haven’t stopped working, and we’ll keep working on it,” he said.