Toward AI Autonomous Navigation for Mechanical Thrombectomy Using Hierarchical Modular Multi-Agent Reinforcement Learning (HM-MARL)

Mechanical thrombectomy (MT) is typically the optimal treatment for acute ischemic stroke involving large vessel occlusions, but access is limited due to geographic and logistical barriers. Reinforcement learning (RL) shows promise in autonomous endovascular navigation, but generalization across ‘long’ navigation tasks remains challenging. We propose a Hierarchical Modular Multi-Agent Reinforcement Learning (HM-MARL) framework for autonomous two-device navigation <italic xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">in vitro</i>, enabling efficient and generalizable navigation. HM-MARL was developed to autonomously navigate a guide catheter and guidewire from the femoral artery to the internal carotid artery (ICA). A modular multi-agent approach was used to decompose the complex navigation task into specialized subtasks, each trained using Soft Actor-Critic RL. The framework was validated in both <italic xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">in silico</i> and <italic xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">in vitro</i> testbeds to assess generalization and real-world feasibility. <italic xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">In silico</i>, a single-vasculature model achieved 92–100% success rates on individual anatomies, while a multi-vasculature model achieved 56–80% across multiple patient anatomies. <italic xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">In vitro</i>, both HM-MARL models successfully navigated 100% of trials from the femoral artery to the right common carotid artery and 80% to the right ICA but failed on the left-side vessel superhuman challenge due to the anatomy and catheter type used in navigation. This study presents the first demonstration of <italic xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">in vitro</i> autonomous navigation in MT vasculature. While HM-MARL enables generalization across anatomies, the simulation-to-real transition introduces challenges. Future work will refine RL strategies using world models and validate performance on unseen <italic xmlns:mml="http://www.w3.org/1998/Math/MathML" xmlns:xlink="http://www.w3.org/1999/xlink">in vitro</i> data, advancing autonomous MT towards clinical translation.