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Uterine-artery embolization versus surgery for symptomatic uterine fibroids. N Engl J Med 2007; 356:360–370. Hehenkamp WJ, Volkers NA, Birnie E, Reekers JA, Ankum WM. Symptomatic uterine fibroids: treatment with uterine artery embolization or hysterectomy-results from the randomized clinical Embolisation versus Hysterectomy (EMMY) Trial. Radiology 2008; 246:823–832. Mara M, Maskova J, Fucikova Z, Kuzel D, Belsan T, Sosna O. Midterm clinical and first reproductive results of a randomized controlled trial comparing uterine fibroid embolization and myomectomy. Cardiovasc Intervent Radiol 2008; 31:73–85. Pron G, Bennett J, Common A, et al, Ontario UFE Collaborative Group. Technical results and effects of operator experience on uterine artery embolization for fibroids: the Ontario Uterine Fibroid Embolization Trial. J Vasc Interv Radiol 2003; 14:545–554. Bratby MJ, Hussain FF, Walker WJ. Outcomes after unilateral uterine artery embolization: a retrospective review. Cardiovasc Intervent Radiol 2008; 31:254–259.

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18. Stall L, Lee J, McCullough M, Nsrouli-Maktabi H, Spies JB. Effectiveness of elective unilateral uterine artery embolization: a case-control study. J Vasc Interv Radiol 2011; 22:716–722. 19. Spies JB. Uterine artery embolization for fibroids: understanding the technical causes of failure. J Vasc Interv Radiol 2003; 14:11–14. 20. Subramanian S, Spies JB. Uterine artery embolization for leiomyomata: resource use and cost estimation. J Vasc Interv Radiol 2001; 12:571–574. 21. Sapoval M, Pellerin O, Rehel JL, et al. Uterine artery embolization for leiomyomata: optimization of the radiation dose to the patient using a flatpanel detector angiographic suite. Cardiovasc Intervent Radiol 2010; 33: 949–954. 22. Abi-Jaoudeh N, Glossop N, Dake M, et al. Electromagnetic navigation for thoracic aortic stent-graft deployment: a pilot study in swine. J Vasc Interv Radiol 2010; 21:888–895. 23. Cochennec F, Riga C, Hamady M, Cheshire N, Bicknell C. Improved catheter navigation with 3D electromagnetic guidance. J Endovasc Ther 2013; 20:39–47.

INVITED COMMENTARY

Robotic Catheterization: The Importance of Evaluation by Interventional Radiologists Barry T. Katzen, MD In this issue of JVIR, Rolls et al (1) describe first-inwoman experience with the use of robotically guided catheters to accomplish embolization of uterine fibroids, an interesting and important milestone in catheterization techniques. One might ask why interventional radiologists, the most skilled angiographers in medicine, should be involved with robotic catheterization when we can seemingly get wherever we need to in the circulation using a sophisticated collection of catheter shapes, styles, materials, and systems, along with specially developed guide wires and other ancillary tools. This is a good question, and I will attempt to answer it in this commentary. First, let’s recognize the work accomplished in the article by Rolls et al. They report an exploratory experience performed in patients treated in 2012 as a new technology was becoming available. A 9-F sheath in the femoral artery was used to deploy a 9-F sheath and a coaxial 6-F catheter within, both of which are shapeable and steerable and have controlled advancement and retraction, all of which may be “driven” from a remote From the Miami Cardiac and Vascular Institute, 8900 North Kendall Drive, Miami, FL 33176. Received and accepted August 27, 2014. Address correspondence to B.T.K.; E-mail: [email protected] The author has not identified a conflict of interest. & SIR, 2014 J Vasc Interv Radiol 2014; 25:1848–1849 http://dx.doi.org/10.1016/j.jvir.2014.08.030

workstation or at a control module at the tableside. As the authors mention, there is now a 6-F robotic catheter with more shape variability and the ability to deliver coaxial catheters or other embolic agents of equivalent outer diameter, such as 0.035-inch coils. Although the authors have attempted to measure robotic catheter function through time to catheterization and have looked at fluoroscopy times, they also stated that more extensive study is required. As we witness the importance of robots increasing in both commercial and medical applications, this article is most significant to radiologists in providing a bellwether of potential technology that could affect operators in both a positive and a negative fashion. The increasing occupational hazards for interventional radiologists and other catheterization specialists are becoming of greater concern (2,3). Increased incidence of orthopedic complications, lifetime radiation exposure, and potential related increased carcinogenesis and cataracts (4) are becoming of greater concern to many of us in the field (5,6). Addressing these concerns can be accomplished in many different ways; however, technology that can move operators and staff further from the x-ray source and reduce the time spent standing while wearing lead aprons might be an important contributor to risk reduction. There are many potential advantages of robotic catheterization, but some of the most interesting aspects of the development of this particular device occurred in the preclinical evaluation as part of the process for

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Figure 1. (a) Note catheter tracking with manual catheterization in a bench top flow model. (b) Tracking data from robotically driven catheterization in the same model. (c) Catheter tracking software demonstrates tracking and wall contacts during arch and left carotid catheterization with manual technique. (Images courtesy of C. Riga, MD.)

receiving approval from the U.S. Food and Drug Administration. Significant histologic changes were demonstrated at 30 days in the manual catheterization group that were not present in the robotic catheterization group in the same animal models. Although the histologic changes may not have clinical significance in humans, these surprising results have led to this author’s interest in exploring further. This preclinical study has been supported by work done by Riga and Cheshire in London (7), where catheter tracking technology was developed to compare wall contact, time, and other benchmarks in catheterization between robotic and manual catheterization and between experienced and inexperienced operators. These studies have suggested that this type of technology might be able to bridge the knowledge gap between experienced and inexperienced operators (8,9), something that may be important moving forward as we continue to lose the foundational experience of diagnostic angiography. In a study looking at wall contact measured by sensors (10), there was a significant difference in models between manual catheterization of the arch and carotid vessels and the amount of wall contact necessary for traditional angiographic techniques versus robotically “driving” catheters into the carotid arteries (Fig 1a, b). These benchmark findings have been confirmed in experimental models in live patients (Fig 1c) where wall contact is displayed superimposed over fluoroscopy in catheterizing a left carotid artery. In conclusion, all of these findings reflect the intriguing nature of robotic catheterization moving forward.

The technology is currently expensive and cumbersome and has other features of early-stage technology development; however, who better to explore the potential benefit than interventional radiologists?

REFERENCES 1. Rolls AE, Riga CV, Bicknell CD, Regan L, Cheshire NJ, Hamady MS. Robot-assisted uterine artery embolization: a first-in-woman safety evaluation of the Magellan system. J Vasc Interv Radiol 2014; 25: 1841–1848. 2. Lipsitz EC, Veith FJ, Ohki T, et al. Does the endovascular repair of aortoiliac aneurysms pose a radiation safety hazard to vascular surgeons? J Vasc Surg 32:704–710. 3. Klein LW, Miller DL, Balter S, et al. Joint Inter-Society Task Force on Occupational Hazards in the Interventional Laboratory. Occupational health hazards in the interventional laboratory: time for a safer environment. J Vasc Interv Radiol 2009; 20:S278–S283. 4. Vano E, Gonzalez L, Beneytez F, et al. Lens injuries induced by occupational exposure in non-optimized interventional radiology laboratories. Br J Radiol 1988; 71:728–733. 5. Bashore TM. Radiation safety in the cardiac catheterization laboratory. Am Heart J 2004; 147:375–378. 6. Lindsay BD, Eichling JO, Ambos HD, Cain ME. Radiation exposure to patients and medical personnel during radio frequency catheter ablation for supraventricular tachycardia. Am J Cardiol 1992; 70: 218–223. 7. Riga C, Bicknell C, Cheshire N, Hamady M. Initial clinical application of a robotically steerable catheter system in endovascular aneurysm repair. J Endovasc Ther 2009; 16:149–153. 8. Riga CV, Bicknell CD, Sidhu R, et al. Advanced catheter technology: is this the answer to overcoming the long learning curve in complex endovascular procedures? Eur J Vasc Endovasc Surg 2011; 42:531–538. 9. Shah C, Riga C, Stoyanov D, et al. Video motion analysis for objective assessment in catheter-based endovascular intervention. Br J Surg 2012; 99(S3):1–16. 10. Riga CV, Bicknell CD, Hamady MS. Evaluation of robotic endovascular catheters for arch vessel cannulation. J Vasc Surg 2011; 54:799–809.

Robotic catheterization: the importance of evaluation by interventional radiologists.

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