key: cord-0849349-h8glyiw1
authors: Megaly, Michael; Brilakis, Emmanouil S.
title: Telesupported procedures: when and how
date: 2020-04-15
journal: Catheter Cardiovasc Interv
DOI: 10.1002/ccd.28878
sha: 0365772d140facf4215b52b3b3a1d438da1185ee
doc_id: 849349
cord_uid: h8glyiw1

Telesupport means guidance of a procedure performed at one location by another clinician at a different location. In a pilot study, 21 percutaneous coronary interventions and nine catheter ablations were successfully performed without complications with telesupport from a remote university hospital. Telesupport is a powerful tool that can be especially useful when urgent care is needed or when transfer is not an option, but it also has limitations, such as network failure or difficulties handling complications; judicious use is key to optimizing outcomes.

• In a pilot study, 21 percutaneous coronary interventions and nine catheter ablations were successfully performed without complications with telesupport from a remote university hospital.

• Telesupport is a powerful tool that can be especially useful when urgent care is needed or when transfer is not an option, but it also has limitations, such as network failure or difficulties handling complications; judicious use is key to optimizing outcomes.

"With great power comes great responsibility." Spider-man, written by Stan Lee.

Case 1: A 50-year-old man presents with anterior myocardial infarction at a small rural hospital. He is presented with two options: on-site percutaneous coronary intervention (PCI) within 30 min by a moderately experienced operator using telesupport or transfer to a larger hospital that will require 90-120 min. He chooses the first option and undergoes successful PCI of the left anterior descending artery. ST segments immediately normalize, and he is discharged 2 days later with mild anterior hypokinesis. 

The strongest reason for telesupported procedures is when treatment is urgently needed to prevent irreversible patient injury, and no other options exist ( Figure 1 ). Case 3 illustrates such a scenario. Another example is the need for procedures in airplane carriers or during space expeditions. The first telesupported procedure performed was a laparoscopic hernia repair on an aircraft carrier. 2 The second strongest indication is when early treatment may be advantageous to patient transfer, such as in STEMI. The third and weakest indication is convenience, that is, patients in Kamisu not willing to travel 1 hr to Tsukuba for an elective procedure. Another application of telesupported procedures is for training (even experienced) operators to perform new procedures or modifications of existing procedures.

There are different potential levels of telesupport. Sharing images, annotating them, and speaking to each other are one level that was used successfully in the present report. A more advanced level would be for the main center operator to perform the procedure in the remote location using a local "robot." Although the currently available system (Corindus, Siemens Healthcare, USA) can help with wiring and balloon/stent delivery, it cannot perform all PCI steps, requiring an operator at the supported site to obtain arterial access, engage the coronary arteries, and load equipment on the robot. 

Procedural telesupport is here to stay and will undoubtedly improve over time. Telesupport can provide significant power, but as with all great powers, responsible use is essential! Understanding its strengths and limitations can help optimize outcomes as illustrated in Case 1 and minimize risks as shown in Case 2. Most F I G U R E 1 Advantages and disadvantages of telesupported procedures [Color figure can be viewed at wileyonlinelibrary.com] patients would probably opt for telesupported PCI in the case of STEMI. However, most may be best served by undergoing their elective procedure at a tertiary center, especially if that procedure is complex.

Last but not least, procedural telesupport may transform initial and continuing medical education. If widely available and at low cost, who would not want to have telesupport even for 

https://orcid.org/0000-0003-3176-6677

Audiovisual telesupport system for cardiovascular catheter interventions: a preliminary report on the clinical implications

First laparoscopic hernia repair onboard an aircraft carrier at sea

Telesupported procedures: when and how