Batjer, H. Hunt

BACKGROUND AND OBJECTIVES: While many trials of the last decade have shifted the paradigm of stroke care toward endovascular therapy, a lack of timely access to centers with neurointerventional capabilities for many patients has remained a significant barrier to care. Endovascular robotic systems are poised to address this need for expanded access through telerobotic procedures, while also benefiting clinical team safety and raising the possibility of improved procedural precision. METHODS: A telerobotic setup consisting of a magnetic field generator and a mechanical advancer was placed with a silicone vascular phantom in an interventional suite in Switzerland and connected by wireless internet to an operator console in Arizona. From the operator console, the neurosurgeon navigated a guidewire and aspiration catheter to simulated middle cerebral artery (MCA) (n = 10) and basilar artery (n = 10) clots in consecutive timed procedural trials in evaluation of system feasibility and operator learning curve. RESULTS: From over 5700 miles away, the neurosurgeon navigated an aspiration catheter to 10 MCA and 10 basilar artery simulated large vessel occlusions. Clot aspiration was attempted in 4 trials and successful in each. Endovascular navigational time over 10 procedural trials to the M1 segment of the MCA and 10 trials to the basilar artery were completed on average in 114 seconds (SD 44.4 seconds) and 134 seconds (SD 65.8 seconds), respectively. Sufficient operator mastery was demonstrated in 20 procedural iterations with an average 77% reduction in navigational time from aortic arch initial to final trials. CONCLUSION: To our knowledge, we present the first intercontinental aspiration thrombectomy in the preclinical setting in comparable time to the clinical practice and demonstrate the early potential of telerobotic navigation. A lack of haptic feedback did not pose a hindrance, and the potential for intuitive operation offers to drive future research and adoption of this telesurgery system.

Abstract Arteriovenous malformations (AVMs) are highly complex vascular lesions characterized by abnormal connections between arteries and an intervening nidus. Definitive and safe treatment of AVMs may require the combination of multiple treatment modalities to address the various complex features of the AVM. 1 Endovascular embolization can be used as an adjuvant to surgery in order to control deep feeders, reduce flow, and address high-risk features such as aneurysms. In addition, by progressively reducing the AVM flow, staged embolization can lead to normalization of peri-AVM hemodynamics and therefore may decrease the risk of postresection hemorrhage. 2,3 In this operative video, we present a case of a 41-yr-old female who presented with progressively worsening left-sided hemiparesis. Magnetic resonance imaging (MRI) and angiography revealed a complex right fronto-parietal AVM with significant associated edema, likely due to the vascular steal phenomenon. The area of edema, which included the motor cortex, was thought to be at high risk for postoperative hemorrhage from normal perfusion pressure breakthrough. We therefore decided to proceed with staged presurgical embolization to gradually normalize the perilesional hemodynamics, and therefore possibly reduce the risk of postoperative morbidity. The patient underwent 3 embolization sessions at 6-wk intervals. An MRI after the last embolization showed near-complete resolution of the fluid-attenuated inversion-recovery (FLAIR) signal around the AVM. Microsurgical resection was performed on the day after the last embolization. The patient tolerated the procedure well and was discharged at her neurological baseline with mild contralateral hemiparesis, which has continued to improve at follow-up. Postoperative angiography showed complete resection of the AVM. The patient consented to the procedure as shown in this operative video and gave informed written consent for use of her images in publication.