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Robotic Vascular Surgery: Current Technologies And Challenges
Keyvon Rashidi, BS1, Charudatta Bavare, MD, MPH2, Maham Rahimi, MD, PhD2.
1Texas A&M School of Engineering Medicine, Houston, TX, USA, 2Department of Cardiovascular Surgery, Houston Methodist Hospital, Houston, TX, USA.

OBJECTIVES: Robotic vascular surgery has not been widely adopted due to the lack of dedicated training pathways, increased operative times, and the lack of suitable instruments for quick control in case of bleeding. This review identifies current robotic vascular technologies, existing devices that can be translated to robotic vascular surgery, and upcoming innovations showing promise in this field.
METHODS: PubMed, Google Scholar, and Scopus were queried using various combinations of terms pertaining to robotic vascular surgery. Studies not published in full, editorials, and articles not written in English were excluded from consideration.
RESULTS: Current robotic vascular technologies include bulldog clamps and Rummel tourniquets. Robotically-deployed bulldog clamps, typically used in Partial Nephrectomies, have been shown to provide lower clamping force than their conventional laparoscopic counterparts, leading to partial occlusion. By contrast, Rummel tourniquets provide circumferential vascular control through a vessel of interest. Albeit investigational, Rummel tourniquets have been used in robotically assisted nephrectomies and IVC-Thrombectomy, with no reported complications. Nevertheless, their use is limited to veins and small noncalcified arteries. REBOA is an existing technology whose use has been demonstrated to be a feasible avenue for emergent vascular control. Although REBOA causes less vessel damage than cross-clamping, its complications include aortic perforation, rupture, and peripheral ischemia. Additionally, balloon-assisted aortic control, requiring a C-arm for fluoroscopic guidance, poses a challenge in robotic vascular surgery as it requires undocking during a catastrophic vascular event. Moreover, challenges using fluoroscopy with the robot also inhibit traditional endoluminal control using balloon catheters. Upcoming investigational technologies that interface with surgical robots show promise in broadening the scope of robotic vascular procedures by increasing the degrees of freedom of end effectors and using magnetically-coupled end effectors. Although such devices have not been FDA-cleared, they would allow for more control over the deployment of vascular robotic clamps and the delivery of endovascular occlusion balloons.
CONCLUSIONS: Advancements in robotically deployed clamps, balloon occlusion devices, and end effector devices hold promise for enhancing surgical interventions. Intra-operative vascular injuries, albeit rare, result in challenging large vessel control with presently available robotic instruments. Technologies needing undocking of the robot present barriers to using them in robotic vascular procedures. Hence, addressing limitations and potential complications is essential for safe implementation and continued progress.
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