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Purpose: Robotic-assisted carotid artery stenting (CAS) cases have been demonstrated with promising results. However, no quantitative measurements have been made to compare manual with robotic-assisted CAS. This study aims to quantify surgical performance using tool tip kinematic data and metrics of precision during CAS with manual and robotic control in an ex vivo model. Materials and Methods: Transfemoral CAS cases were performed in a high-fidelity endovascular simulator. Participants completed cases with manual and robotic techniques in 2 different carotid anatomies in random order. C-arm angulations, table position, and endovascular devices were standardized. Endovascular tool tip kinematic data were extracted. We calculated the spectral arc length (SPARC), average velocity, and idle time during navigation in the common carotid artery and lesion crossing. Procedural time, fluoroscopy time, movements of the deployed filter wire, precision of stent, and balloon positioning were recorded. Data were analyzed and compared between the 2 modalities. Results: Ten participants performed 40 CAS cases with a procedural success of 100% and 0% residual stenosis. The median procedural time was significantly higher during the robotic-assisted cases (seconds, median [interquartile range, IQR]: 128 [49.5] and 161.5 [62.5], p=0.02). Fluoroscopy time differed significantly between manual and robotic-assisted procedures (seconds, median [IQR]: 81.5 [32] and 98.5 [39.5], p=0.1). Movement of the deployed filter wire did not show significant difference between manual and robotic interventions (mm, median [IQR]: 13 [10.5] and 12.5 [11], p=0.5). The postdilation balloon exceeded the margin of the stent with a median of 2 [1] mm in both groups. Navigation with robotic assistance showed significantly lower SPARC values (–5.78±3.14 and –8.63±3.98, p=0.04) and higher idle time values (8.92±8.71 and 3.47±3.9, p=0.02) than those performed manually. Conclusions: Robotic-assisted and manual CAS cases are comparable in the precision of stent and balloon positioning. Navigation in the carotid artery is associated with smoother motion and higher idle time values. These findings highlight the accuracy and the motion stabilizing capability of the endovascular robotic system. Clinical Impact Robotic assistance in the treatment of peripheral vascular disease is an emerging field and may be a tool for radiation protection and the geographic distribution of endovascular interventions in the future. This preclinical study compares the characteristics of manual and robotic-assisted carotid stenting (CAS). Our results highlight, that robotic-assisted CAS is associated with precise navigation and device positioning, and smoother navigation compared to manual CAS. 

Abstract Endovascular navigation proficiency requires a significant amount of manual dexterity from surgeons. Objective performance measures derived from endovascular tool tip kinematics have been shown to correlate with expertise; however, such metrics have not yet been used during training as a basis for real-time performance feedback. This paper evaluates a set of velocity-based performance measures derived from guidewire motion to determine their suitability for online performance evaluation and feedback. We evaluated the endovascular navigation skill of 75 participants using three metrics (spectral arc length, average velocity, and idle time) as they steered tools to anatomical targets using a virtual reality simulator. First, we examined the effect of navigation task and experience level on performance and found that novice performance was significantly different from intermediate and expert performance. Then we computed correlations between measures calculated online and spectral arc length, our "gold standard" metric, calculated offline (at the end of the trial, using data from the entire trial). Our results suggest that average velocity and idle time calculated online are strongly and consistently correlated with spectral arc length computed offline, which was not the case when comparing spectral arc length computed online and offline. Average velocity and idle time, both time-domain based performance measures, are therefore more suitable measures than spectral arc length, a frequency-domain based metric, to use as the basis of online performance feedback. Future work is needed to determine how to best provide real-time performance feedback to endovascular surgery trainees based on these metrics.