Mixed reality applied to surgical planning and tailoring of carotid endarterectomies

Perioperative three-dimensional (3D) anatomical visualization with mixed reality (MxR) may have a relevant impact on adequate carotid endarterectomy (CEA) planning compared to standard imaging studies, by highlighting patient specific anatomical features and allowing the rehearsal of the relevant surgical steps in 3D.

All consecutive CEAs planned with MxR between January 2022 and July 2024 were prospectively included. Using the preoperative head and neck CT-angiography (CTA) and/or MR-angiography (MRA), skin, skull, cervical spine and vascular anatomy including plaques were segmented. The resulting 3D interactive reconstructed object was matched on the patient with MxR glasses in the operating room after patient positioning and drawing initial skin incision. The impact of 3D visualization on surgical planning and anatomical understanding was documented and usability testing was performed.

Forty-nine CEAs were included. Mean 3D reconstruction preparation time was 17 ± 8 min. Mean duration of intraoperative 3D reconstruction use was 5 ± 2 min. The supervising surgeon significantly altered (shortening) the skin incision in 16 cases (33%). Higher scores were given to the domains Ease of Use and Satisfaction.

CEA planning with MxR seems to have an impact on anatomical understanding for both less experienced neurosurgeons and highly experienced neurosurgeons performing more than 25 CEAs per year. Future research should focus on quantification of the benefits in surgical training and assess the impact on surgical outcomes.