Six Fr right radial access was secured and the operator manually cannulated the LMS with a 6 Fr AL1 guiding catheter. Following successful and stable cannulation, the guiding catheter was connected to the robotic arm, and the rest of the procedure was completed from the remote workstation (Supplementary material, Figure S3). A Runthrough NS Floppy wire (Terumo systems, Somerset, NJ, USA) was selected and robotically advanced to the distal vessel, with the tortuosity and diseased segment successfully navigated using a combination of manual joystick controls and pre-set automation techniques (Figure 1C). A 2.5 × 27 mm non-compliant (NC) balloon was used to pre-dilate the lesion. Precise measurement (1 mm precision) of the lesion length was performed using the robotic system and accordingly a 3.0 × 38 mm drug-eluting stent (Promus PREMIER, Boston Scientific, Marlborough, MA, USA) was advanced and successfully implanted at the intended site (Figure 1D). Post-dilatation of the proximal portion of the stent was performed with a 3.5 × 15 mm NC balloon. Following main vessel stenting, the main vessel wire was retracted and robotically advanced into the OM1 branch which was treated with balloon-only angioplasty using a 2.0 × 12 mm NC inflated at 10 atm (Figure 1E).

Final angiography revealed a good angiographic result, optimal stent expansion with no complications (Figure 1F). Fluoroscopy time was 22 minutes, radiation dose was 943 mGy and total contrast volume was 150 ml.

This case demonstrates how the R-PCI system can be used to safely and successfully treat complex lesions. Despite the lack of haptic feedback, wiring of this tortuous vessel was achieved using the joystick controls manually aided by the built-in automated robotic movements. The CorPath GRX system can accommodate multiple coronary wires and devices simultaneously. In such instances, one wire and one device are allocated to the active drive and can be controlled from the console, whilst the remaining wires and devices cannot be maneuvered but remained fixed in the passive drive. This can enable operators to treat complex lesions including bifurcations and perform final kissing inflations when required. The presence of a short LMS required repeated repositioning and stabilization maneuvers of the guiding catheter, which were all performed using the guide catheter joystick control. During initial wiring, the guide catheter disengaged into the aorta with subsequent loss of wire position. With the robotic controls, the guide catheter was safely manipulated back into a more stable position achieving semi-selective cannulation of the Cx artery.

Worldwide experience with R-PCI systems is growing, enabling increasingly complex coronary lesions to be treated safely and effectively, without compromising procedural time, and with improved operator safety [4, 5]. In our case, the primary operator completed the entire procedure without wearing any radioprotection sat at the robotic console, which was located within the operating room.

Supplementary material

Supplementary material is available at https://journals.viamedica.pl/kardiologia_polska.

Article information

Conflict of interest: None declared.

Open access: This article is available in open access under Creative Common Attribution-Non-Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0) license, allowing to download articles and share them with others as long as they credit the authors and the publisher, but without permission to change them in any way or use them commercially. For commercial use, please contact the journal office at kardiologiapolska@ptkardio.pl.

How to cite: Zelias A, Khokhar AA, Proniewska K, et al. A Percutaneous coronary intervention of a tortuous and complex circumflex lesion using the robotic CorPath GRX system. Kardiol Pol. 2021; 79(9): 1044–1045, doi: 10.33963/KP.a2021.0057.

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