Augmented Reality in Vascular and Endovascular Surgery: Scoping Review

Abstract

Background: Technological advances have transformed vascular intervention in recent decades. In particular, improvements in imaging and data processing have allowed for the development of increasingly complex endovascular and hybrid interventions. Augmented reality (AR) is a subject of growing interest in surgery, with the potential to improve clinicians' understanding of 3D anatomy and aid in the processing of real-time information. This study hopes to elucidate the potential impact of AR technology in the rapidly evolving fields of vascular and endovascular surgery.

Objective: The aim of this review is to summarize the fundamental concepts of AR technologies and conduct a scoping review of the impact of AR and mixed reality in vascular and endovascular surgery.

Methods: A systematic search of MEDLINE, Scopus, and Embase was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. All studies written in English from inception until January 8, 2021, were included in the search. Combinations of the following keywords were used in the systematic search string: ("augmented reality" OR "hololens" OR "image overlay" OR "daqri" OR "magic leap" OR "immersive reality" OR "extended reality" OR "mixed reality" OR "head mounted display") AND ("vascular surgery" OR "endovascular"). Studies were selected through a blinded process between 2 investigators (JE and AS) and assessed using data quality tools.

Results: AR technologies have had a number of applications in vascular and endovascular surgery. Most studies (22/32, 69%) used 3D imaging of computed tomography angiogram-derived images of vascular anatomy to augment clinicians' anatomical understanding during procedures. A wide range of AR technologies were used, with heads up fusion imaging and AR head-mounted displays being the most commonly applied clinically. AR applications included guiding open, robotic, and endovascular surgery while minimizing dissection, improving procedural times, and reducing radiation and contrast exposure.

Conclusions: AR has shown promising developments in the field of vascular and endovascular surgery, with potential benefits to surgeons and patients alike. These include reductions in patient risk and operating times as well as in contrast and radiation exposure for radiological interventions. Further technological advances are required to overcome current limitations, including processing capacity and vascular deformation by instrumentation.

Keywords: augmented reality; endovascular; head-mounted display; mobile phone; surgery; vascular.

Figure 1

Search strategy. Search of MEDLINE, Scopus, and Embase databases. Exclusions shown.

Figure 2

During the procedure, different information was overlaid onto the native 2D fluoroscopic image to guide instrument placement: (A) none, (B) centerlines and key points can be projected, and (C) artificially enhanced aortic volume. Reprinted from European Journal of Vascular & Endovascular Surgery, 49/3, Kaladji A, Dumenil A, Mahé G, Castro M, Cardon A, Lucas A, Haigron P, Safety and accuracy of endovascular aneurysm repair without pre-operative and intra-operative contrast agent, 255-261, 2015, with permission from Elsevier [33].

Figure 3

View from HoloLens display of 3D vasculature from 3D ultrasound being projected onto a phantom. Reproduced from García-Vázquez V et al [27] under the Creative Commons Attribution Non-Commercial License.

Figure 4

Computed tomography–derived 3D model is superimposed onto camera images. Doughnut-shaped fiducial markers on the limb help match images so that the target artery and its branches can be overlaid onto the limb as red (A) or blue (B) lines. Reprinted by permission from the Springer Nature Customer Service Centre GmbH: Springer Nature. New simple image overlay system using a tablet PC for pinpoint identification of the appropriate site for anastomosis in peripheral arterial reconstruction. Mochizuki Y, Hosaka A, Kamiuchi H, Nie JX, Masamune K, Hoshina K, et al. 2016 [40].

Figure 5

Screen capture of augmented reality–assisted surgery system developed by Aly [6]. Fiducial marker (sterile suture pack) used for registration and tracking with 3D model derived from computed tomography angiogram superimposed from mobile phone. (A) Tracking marker, (B) common femoral vein, and (C) inguinal ligament. Reproduced under the Creative Commons Attribution License CC-BY 4.0.

Figure 6

Early augmented reality interventional simulator design. Reproduced from Anderson et al [45], with permission from © Georg Thieme Verlag KG. Note: The permission of the figure stays with the publisher, and any further reuse will need explicit permission from the publisher.