Autonomous Vascular Access Devices: Current Solutions and Future Challenges

Central venous cannulation is essential for life-saving interventions including resuscitation of critically ill patients, hemodynamic monitoring, endovascular intervention, pressor therapy, dialysis and apheresis, and extracorporeal life support. Cannulation of major arteries is required for cardiac catheterization, endovascular interventions such as arterial stenting or aneurysm repair, as well as emergency interventions such as intra-aortic balloon pumps and extracorporeal membrane oxygenation (ECMO). Both venous and arterial cannulation are commonly performed by specialized providers, and both continue to have significant complications despite the widespread use of ultrasound imaging to aid in cannulation. In the United States, clinicians manually place an estimated 5.0-5.5 million central venous catheters (CVCs) and >1 million arterial lines annually. Despite guideline‑driven adoption of real‑time ultrasound, first‑pass success remains a challenge, and mechanical complications occur in 5%-19% of attempts. These complications cause additional patient harm and suffering and central line-associated bloodstream infections alone are estimated to exceed $1.3 billion annually. Autonomous or semi‑autonomous "autonomous vascular access" (AVA) platforms have the promise to standardize technique, accelerate placement by a wider range of providers, extend cannulation capability to austere settings, and reduce complication‑related morbidity.

This review summarizes (1) current civilian practice, guidelines, outcomes and epidemiology of vascular access; (2) emergency, combat and trauma‑care imperatives that are catalyzing AVA development; (3) fundamental principles and pitfalls that automation must address; (4) experimental models for device evaluation; (5) the present pipeline of robotic and image‑guided systems; and (6) essential design criteria for an ideal AVA device.

A comprehensive literature search of PubMed, Scopus, IEEE Xplore, and Google Scholar (January 2015 -December 2025) was conducted using the terms "central venous catheter," "arterial cannulation," "robotic vascular access," "automated vascular access," and related phrases. English‑language guidelines from the Society for Vascular Surgery, American Society of Anesthesiologists, European Society for Vascular Surgery, American College of Emergency Physicians, and Joint Trauma System (JTS) were reviewed.

Contemporary practice achieves ultrasound‑guided first‑pass pooled success of 81.5% for all CVC access sites placed by attending physicians but an estimated 60%-75% when performed by trainees. Pneumothorax (0.5%-3%), arterial puncture (1%-3%), malposition (4%-10%), and catheter‑associated bloodstream infection remain prevalent. In military Role 1-3 environments, rapid arterial or large‑bore venous access is prerequisite for REBOA, damage‑control resuscitation, and forward ECMO; however, skilled personnel may be scarce, and environmental stressors degrade performance. Benchtop phantoms, perfused swine, and pulsatile cadavers now provide rigorous testbeds for AVA systems. First‑generation platforms (AI‑GUIDE, CERTA, and Vu-Path) integrate ultrasound vessel segmentation, robotics, haptic force sensing, artificial intelligence (AI) and closed‑loop needle control, achieving 90%-100% success in limited series using phantom, porcine, or limited human series.

AVA technology remains in early-stage development, with promising but limited evidence from benchtop, animal, cadaveric, and small feasibility studies. No platform has yet demonstrated safety, effectiveness, and operational reliability in adequately powered clinical or military field trials. For adoption, systems must deliver real‑time, closed‑loop imaging; universal catheter compatibility; portability; robust safety interlocks; cyber‑secure data integration; and cost parity with manual cannulation. Multicenter trials powered for clinical and economic endpoints are now imperative.