By David Fischel

Surgical practice has undergone remarkable transformation over the last century. The advent of antibiotics and advancements in technique ushered in a new era where open surgery became safer and more routine. Yet, as medicine evolved, so too did its ambitions: less invasive, faster recovery, and greater precision. Laparoscopic surgery, a breakthrough in minimally invasive techniques, achieved mainstream success in the 1980s and 1990s, fundamentally redefining patient care.

Endovascular surgery followed a similar arc. Though the first catheterization was documented in 1929, it wasn’t until the latter part of the 20th century that endovascular procedures reshaped fields like interventional cardiology, electrophysiology, and vascular surgery. The past 15 years have been particularly transformative, especially with the growth of catheter ablation for cardiac arrhythmias.
Robotic promise meets clinical reality
Given the broader healthcare shift toward minimally invasive interventions, the integration of robotics into endovascular surgery seemed inevitable. In laparoscopic surgery, robotics swiftly became the gold standard, enhancing precision and reducing surgeon fatigue.

Endovascular surgery is an amazing feat of human ingenuity. With a small incision on the leg, we are able to do heart surgery or even brain surgery. This is done with a physician navigating a flexible device at the point of incision through incredibly delicate vasculature and operating in a target area that could be two, three feet away. This could be compared to an artist having to hold a pencil by the eraser to draw a masterpiece. Robotics can help overcome this challenge, yet they have yet to be implemented at the same scale as laparoscopic.

Barriers rooted in complexity
Several persistent hurdles historically limited robotics adoption in endovascular surgery. Success depends on the seamless orchestration of guidewires, catheters, sheaths, imaging, and mapping systems which have been traditionally designed for manual use and often manufactured independently. Early robotic systems mimicked manual techniques without fundamentally improving them, failing to deliver the transformative precision or safety needed to justify a paradigm shift. High capital costs and disruptive installation requirements, including room retrofits and dedicated power systems, placed significant barriers in the path of adoption. Early systems also extended procedure times, clashing with the need for efficiency in high-volume specialties. Without strong randomized controlled trial data, early robotics adoption depended largely on observational studies and pioneering clinicians, making broader buy-in difficult.

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