In the era of transition from fiction to reality: Robotic-assisted neurointervention-a systematic review and meta-analysis

Objective: In recent years, the application of robotic assistance in diagnostic and therapeutic endovascular neurointerventional procedures has gained notable attention. In this systematic review and meta-analysis, we aim to evaluate the feasibility, safety, and current indications of robotic-assisted neurointerventions and to assess the degree of robotic assistance and reasons for unplanned manual conversion from robotic assistance.

Methods: We searched Medline, Scopus, Web of Science, and Cochrane Library databases following PRISMA guidelines and included studies with ≥ 4 patients reporting on robotic-assisted neurointerventions. We analyzed outcomes including technical success, manual conversion, procedure-related complications, morbidity, and mortality with a random-effects meta-analysis. We also identified causes of manual conversion and conducted subanalyses by procedure type and robotic system.

Results: Thirteen studies, comprising 538 robotic-assisted neurointerventions, were included. Procedures were primarily diagnostic cerebral angiograms (n = 348), cerebral aneurysm embolizations (n = 127), and carotid artery stenting (n = 37). The CorPath GRX (Corindus) robotic system was employed in the majority of cases (n = 355). Across all studies, the technical success rate was 93%, and the procedure-related complication rate was 0.7%. Manual steps were necessary in all cases due to inherent procedural requirements. Unplanned manual conversion from robotic assistance was necessary in 7% of cases. Further analysis of failures identified challenging anatomies, loss of working length, and mechanical failures as the most common reasons.

Conclusions: This systematic review and meta-analysis found that, with a certain degree of manual assistance, robotic-assisted neurointervention is highly feasible, safe, and capable of performing DCA, CAS, and therapeutic neurointerventions that can be executed with a single microcatheter involving simple coiling, stent-assisted coiling, and flow diverter embolization. However, unplanned manual conversion is not uncommon. Improvements in working length and mechanical parts, including the cassette robotic arm and console, as well as CorPath GRX compatibility with 0.035-inch wires, may reduce the rates of manual conversion for current indications. Nonetheless, technical adaptations are essential to broaden the scope of therapeutic neurointervention indications.