Case Report

Robotic-Assisted PCI Performed in LAD/Diagonal Bifurcation Case

Frances O. Wood, MD, FACC, WakeMed Heart & Vascular, Raleigh, North Carolina

Frances O. Wood, MD, FACC, WakeMed Heart & Vascular, Raleigh, North Carolina

Robotic-assisted percutaneous coronary intervention (PCI) technology has evolved to assist operators in simple and complex lesions. Robotic assistance adds precision, decreases radiation to the patient and staff, and reduces time wearing lead even with planned manual steps to the intervention.

Case Report

A 75-year-old female with morbid obesity, diabetes, and hypertension underwent staged intervention to the mid left anterior descending artery (LAD) one month after inferior ST-elevation myocardial infarction treated with a single drug-eluting stent to the distal right coronary artery. She had exertional dyspnea despite euvolemia and two anti-anginals. Left ventricular function was normal. Apical LAD disease was to be treated medically.

Figure 1 shows a severe mid LAD lesion involving the bifurcation of the 1st diagonal, which has moderate ostial disease and significant tortuosity. The plan was provisional bifurcation stenting using robotic-assisted PCI with the CorPath GRX system (Corindus, A Siemens Healthineers Company). There was a size mismatch between the diagonal and LAD. The robot was used for all steps unless stated manually, using the wire, balloon/stent, and guide catheter joysticks. A 6 French extra support (XB) 3.0 guide catheter was engaged manually into the left main artery. An .014-inch wire was advanced down the diagonal by quickly rotating and pushing forward the wire joystick in a similar fashion to spinning the wire with the fingertips. The wire was then placed in the accessory parking track. A second .014-inch wire was advanced down the LAD using a forward motion of the wire joystick and the Rotate on Retract tool. ROR uses automation to redirect the wire immediately upon pullback of the wire joystick. The LAD and diagonal were predilated with 3.0 NC and 2.5 NC balloons, respectively (Figures 2-3). Manual intravascular ultrasound (IVUS) showed the distal LAD reference to be 3.7 mm while the proximal reference was 4.4 mm. The LAD was stented with a 3.5 x 16 mm drug-eluting stent using the 1 mm precise positioning tool while the diagonal wire was in the accessory parking track. The LAD was post dilated with a 3.5 non-compliant (NC) balloon at high pressure and the proximal segment was dilated with a 4.5 NC balloon. Diagonal and LAD wires were swapped to control and accessory parking tracks, respectively, to allow for removal of the jailed diagonal wire with guide control. The active guide catheter joystick was pulled back as the diagonal wire was withdrawn to prevent the guide from diving. The diagonal wire was then advanced back down the diagonal. Simultaneous kissing balloon inflations with 2.5 NC and 3.5 NC balloons were performed manually (Figure 4). Repeat IVUS showed excellent stent apposition, and no proximal or distal edge dissection. Final angiography (Figure 5) confirmed TIMI-III flow down the diagonal with minimal luminal narrowing. The case utilized 805 mGy and 16.3 minutes of fluoroscopy time.

Discussion

This case exemplifies how robotic-assisted PCI can be used in complex cases with planned steps performed manually. The console provides guide, balloon/stent, and wire control simultaneously, allowing the operator to perform the intervention safely and with precision. There are professional and patient benefits in partial and 100% robotic cases: 1) The operator’s skills progress to further enhance the field of robotics; 2) The patient and operator benefit by reduced radiation, increased precision, and decreased standing and use of lead aprons. While the ultimate long-term goal in robotic-assisted PCI is providing excellent, consistent care to all patients, especially those in remote regions, the robotic interventional field gains knowledge and drives technology forward with each case performed. 

Disclosure: Dr. Wood reports she is a consultant to Corindus.

Dr. Wood can be contacted at fwood@wakemed.org