Experienced Endovascular Interventionalists Objectively Improve their Skills by Attending Carotid Artery Stent Training Courses

Fundamental Technical Skills of Endovascular Surgery: A Preliminary Study on Its Impact on Skills and Stress during Procedures

BACKGROUND

Our objective is twofold: determining if simulation allows residents to reach proficient surgeons' performance concerning fundamental technical skills of endovascular surgery (FEVS) while investigating effects of the program on surgeons' stress.

METHODS

Using a FEVS training simulator, 8 endovascular FEVS were performed by vascular surgery residents (simulator-naive or simulator-experienced residents [SER]) and seniors. Total time needed to complete the 8 tasks, called total completion time (TCT), was the main evaluation criterion. Analgesia Nociception Index (ANI) was monitored during simulation. Likert scale questionnaire was filled out after each simulation.

RESULTS

For each task, TCT was significantly lower for SER and seniors than simulator-naive residents (P = 0.0163). After only 5 simulations, SER were able to reach and even exceed the seniors' level in terms of TCT, with a median time of 10.8 min for SER and 11.9 min for seniors, and wire's movements with a median distance during cannulation of 4.44 m for SER and 4.17 m for seniors. Seniors remained better than SER in terms of precise wire manipulation (wire movement after cannulation), 4.17 m against 4.44 m (3.72-5.96), respectively. Based on the Likert scale stress analysis, seniors felt less stressed than both residents' groups (P = 0.0618). Seniors' initial ANI and mean ANI over the session were significantly lower than those of the residents, P = 0.0358 and P = 0.0250, respectively.

CONCLUSIONS

We showed that 5 simulation sessions allowed residents to reach experienced surgeons' capacities on FEVS concerning TCT. Subjectively, seniors felt less stressed than residents, contrary to the results of our objective measures of stress.

Training for endovascular therapy of acute arterial disease and procedure-related complication: An extracorporeally-perfused human cadaver model study

PURPOSE

The aim of this study was to evaluate the usability of a recently developed extracorporeally-perfused cadaver model for training the angiographic management of acute arterial diseases and periprocedural complications that may occur during endovascular therapy of the lower extremity arterial runoff.

MATERIALS AND METHODS

Continuous extracorporeal perfusion was established in three fresh-frozen body donors via inguinal and infragenicular access. Using digital subtraction angiography for guidance, both arterial embolization (e.g., embolization using coils, vascular plugs, particles, and liquid embolic agents) and endovascular recanalization procedures (e.g., manual aspiration or balloon-assisted embolectomy) as well as various embolism protection devices were tested. Furthermore, the management of complications during percutaneous transluminal angioplasty, such as vessel dissection and rupture, were exercised by implantation of endovascular dissection repair system or covered stents. Interventions were performed by two board-certified interventional radiologists and one resident with only limited angiographic experience.

RESULTS

Stable extracorporeal perfusion was successfully established on both thighs of all three body donors. Digital subtraction angiography could be performed reliably and resulted in realistic artery depiction. The model allowed for repeatable training of endovascular recanalization and arterial embolization procedures with typical tactile feedback in a controlled environment. Furthermore, the handling of more complex angiographic devices could be exercised. Whereas procedural success was be ascertained for most endovascular interventions, thrombectomies procedures were not feasible in some cases due to the lack of inherent coagulation.

CONCLUSION

The presented perfusion model is suitable for practicing time-critical endovascular interventions in the lower extremity runoff under realistic but controlled conditions.

A Scoping Review of Simulation-Based Training Paradigms for Carotid Artery Endarterectomy and Carotid Artery Stenting

BACKGROUND

Surgical simulation has come to the forefront to enhance the training of residents. The aim of our scoping review is to analyze the available simulation-based carotid revascularization techniques, including carotid endarterectomy (CEA) and carotid artery stenting (CAS) and suggest critical steps for evaluating competency in a standardized fashion.

METHODS

A scoping review of all reports on simulation-based carotid revascularization techniques including CEA and CAS was performed in PubMed/MEDLINE, Scopus, Embase, Cochrane, Science Citation Index Expanded, Emerging Sources Citation Index, and Epistemonikos databases. Data were collected according to the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. The English language literature was searched from January 1, 2000 to January 9, 2022. The outcomes evaluated included measures of assessment of operator performance.

RESULTS

Five CEA and 11 CAS manuscripts were included in this review. The methods of assessments employed by these studies to judge performance were comparable. The 5 CEA studies sought to validate and demonstrate improved performance with training or distinguish surgeons by their experience level, either through assessing operative performance or end-product results. The 11 CAS studies used 1 of 2 types of commercial simulators and focused on determining the efficacy of simulators as teaching tools. By examining the steps of the procedure associated with preventable perioperative complications, it provides a reasonable framework for determining which elements of the procedure should be emphasized most. Furthermore, using potential errors as a basis for assessment of competency could reliably distinguish operators based on level of experience.

CONCLUSIONS

Competency-based simulation training is becoming more relevant as our surgical training paradigm shifts with the increased scrutiny within training programs of work-hour regulations and the need to develop a curriculum to assess our trainees' ability to perform specific operations competently during their stipulated training period. Our review has given us an insight into the current efforts in this space regarding 2 specific procedures that are key for all vascular surgeons to master. Although many competency-based modules are available, there is a lack of standardization in the grading/rating system of what surgeons consider vital steps of each procedure to assess these simulation-based modules. Therefore, the next steps of curriculum development should be based on standardization efforts for the different protocols available.

An Image Information-Based Objective Assessment Method of Technical Manipulation Skills for Intravascular Interventions

The clinical success of vascular interventional surgery relies heavily on a surgeon's catheter/guidewire manipulation skills and strategies. An objective and accurate assessment method plays a critical role in evaluating the surgeon's technical manipulation skill level. Most of the existing evaluation methods incorporate the use of information technology to find more objective assessment models based on various metrics. However, in these models, sensors are often attached to the surgeon's hands or to interventional devices for data collection, which constrains the surgeon's operational movements or exerts an influence on the motion trajectory of interventional devices. In this paper, an image information-based assessment method is proposed for the evaluation of the surgeon's manipulation skills without the requirement of attaching sensors to the surgeon or catheters/guidewires. Surgeons are allowed to use their natural bedside manipulation skills during the data collection process. Their manipulation features during different catheterization tasks are derived from the motion analysis of the catheter/guidewire in video sequences. Notably, data relating to the number of speed peaks, slope variations, and the number of collisions are included in the assessment. Furthermore, the contact forces, resulting from interactions between the catheter/guidewire and the vascular model, are sensed by a 6-DoF F/T sensor. A support vector machine (SVM) classification framework is developed to discriminate the surgeon's catheterization skill levels. The experimental results demonstrate that the proposed SVM-based assessment method can obtain an accuracy of 97.02% to distinguish between the expert and novice manipulations, which is higher than that of other existing research achievements. The proposed method has great potential to facilitate skill assessment and training of novice surgeons in vascular interventional surgery.

The role of high-fidelity simulation in the acquisition of endovascular surgical skills: a systematic review

INTRODUCTION

The widespread introduction of minimally invasive endovascular techniques in cardiovascular surgery has necessitated a transition in the psychomotor skillset of trainees and surgeons. Simulation has previously been used in surgical training; however, there is limited high quality evidence regarding the role of simulation-based training on the acquisition of endovascular skills. This systematic review aimed to systematically appraise the currently available evidence regarding endovascular high-fidelity simulation interventions, to describe the overarching strategies used, the learning outcomes addressed, the choice of assessment methodology, and the impact of education on learner performance.

METHODS

A comprehensive literature review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement using relevant keywords to identify studies evaluating simulation in the acquisition of endovascular surgical skills. References of review articles were screened for additional studies.

RESULTS

A total of 1081 studies were identified (474 after removal of duplicates). There was marked heterogeneity in methodologies and reporting of outcomes. Quantitative analysis was deemed inappropriate due to the risk of serious confounding and bias. Instead, a descriptive synthesis was performed, summarising key findings and quality components. Eighteen studies were included in the synthesis (15 observational, 2 case-control and 1 randomised control studies). Most studies measured procedure time, contrast usage, and fluoroscopy time. Other metrics were recorded to a lesser extent. Significant reductions were noted in both procedure and fluoroscopy times with the introduction of simulation-based endovascular training.

CONCLUSION

The evidence regarding the use of high-fidelity simulation in endovascular training is very heterogeneous. The current literature suggests simulation-based training leads to improvements in performance, mostly in terms of procedure and fluoroscopy time. High-quality randomised control trials are needed to establish the clinical benefits of simulation training, sustainability of improvements, transferability of skills and its cost-effectiveness.

Association of Suturing Technical Skill Assessment Scores Between Virtual Reality Simulation and Live Surgery

Introduction: Robotic surgical performance, in particular suturing, has been linked to postoperative clinical outcomes. Before attempting live surgery, virtual reality (VR) simulators afford opportunities for training surgeons to learn fundamental technical skills. Herein, we evaluate the association of suturing technical skill assessments between VR simulation and live surgery, and functional clinical outcomes. Materials and Methods: Twenty surgeons completed a VR suturing exercise on the Mimic™ Flex VR simulator and the anterior vesicourethral anastomosis during robot-assisted radical prostatectomy (RARP). Three independent and blinded graders provided technical skill scores using a validated assessment tool. Correlations between VR and live scores were assessed by Spearman's correlation coefficients (ρ). In addition, 117 historic RARP cases from participating surgeons were extracted, and the association between VR technical skill scores and urinary continence recovery was assessed by a multilevel mixed-effects model. Results: A total of 20 (6 training and 14 expert) surgeons participated. Statistically significant correlations for scores provided between VR simulation and live surgery were found for overall and needle driving scores (ρ = 0.555, p = 0.011; ρ = 0.570, p = 0.009, respectively). A subanalysis performed on training surgeons found significant correlations for overall scores between VR simulation and live surgery (ρ = 0.828, p = 0.042). Expert cases with high VR needle driving scores had significantly greater continence recovery rates at 24 months after RARP (98.5% vs 84.9%, p = 0.028). Conclusions: Our study found significant correlations in technical scores between VR and live surgery, especially among training surgeons. In addition, we found that VR needle driving scores were associated with continence recovery after RARP. Our data support the association of skill assessments between VR simulation and live surgery and potential implications for clinical outcomes.

A Systematic Review of Simulation-Based Training in Vascular Surgery

Introduction

Recent advancements in surgical technology, reduced working hours, and training opportunities exacerbated by the COVID-19 pandemic have led to an increase in simulation-based training. Furthermore, a rise in endovascular procedures has led to a requirement for high-fidelity simulators that offer comprehensive feedback. This review aims to identify vascular surgery simulation models and assess their validity and levels of effectiveness (LoE) for each model in order to successfully implement them into current training curricula.

Methods

PubMed and EMBASE were searched on January 1, 2021, for full-text English studies on vascular surgery simulators. Eligible articles were given validity ratings based on Messick’s modern concept of validity alongside an LoE score according to McGaghie’s translational outcomes.

Results

Overall 76 eligible articles validated 34 vascular surgery simulators and training courses for open and endovascular procedures. High validity ratings were achieved across studies for: content (35), response processes (12), the internal structure (5), relations to other variables (57), and consequences (2). Only seven studies achieved an LoE greater than 3/5. Overall, ANGIO Mentor was the most highly validated and effective simulator and was the only simulator to achieve an LoE of 5/5.

Conclusions

Simulation-based training in vascular surgery is a continuously developing field with exciting future prospects, demonstrated by the vast number of models and training courses. To effectively integrate simulation models into current vascular surgery curricula and assessments, there is a need for studies to look at trainee skill retention over a longer period of time. A more detailed discussion on cost-effectiveness is also needed.

Evaluation of a modular in vitro neurovascular procedure simulation for intracranial aneurysm embolization

BACKGROUND

Rapid development in endovascular aneurysm therapy continuously drives demand for suitable neurointerventional training opportunities.

OBJECTIVE

To investigate the value of an integrated modular neurovascular training environment for aneurysm embolization using additively manufactured vascular models.

METHODS

A large portfolio of 30 patient-specific aneurysm models derived from different treatment settings (eg, coiling, flow diversion, flow disruption) was fabricated using additive manufacturing. Models were integrated into a customizable neurointerventional simulator with interchangeable intracranial and cervical vessel segments and physiological circuit conditions ('HANNES'; Hamburg ANatomic Neurointerventional Endovascular Simulator). Multiple training courses were performed and participant feedback was obtained using a questionnaire.

RESULTS

Training for aneurysm embolization could be reliably performed using HANNES. Case-specific clinical difficulties, such as difficult aneurysm access or coil dislocation, could be reproduced. During a training session, models could be easily exchanged owing to standardized connectors in order to switch to a different treatment situation or to change from 'treated' back to 'untreated' condition. Among 23 participants evaluating hands-on courses using a five-point scale from 1 (strongly agree) to 5 (strongly disagree), HANNES was mostly rated as 'highly suitable for practicing aneurysm coil embolization' (1.78±0.79).

CONCLUSION

HANNES offers a wide variability and flexibility for case-specific hands-on training of intracranial aneurysm treatment, providing equal training conditions for each situation. The high degree of standardization offered may be valuable for analysis of device behavior or assessment of physician skills. Moreover, it has the ability to reduce the need for animal experiments.

An Evaluation of the Impact of High-Fidelity Endovascular Simulation on Surgeon Stress and Technical Performance

OBJECTIVE

To measure the physiological stress response associated with high-fidelity endovascular team simulation.

DESIGN

This is a prospective cohort study.

SETTING

This study was performed at St Mary's Hospital (Imperial College London, London, UK), in a tertiary setting.

PARTICIPANTS

Thirty-five participants (10 vascular surgical residents, 4 surgical interns, 12 theatre nurses, 2 attending vascular surgeons, 6 medical students and 1 technician) were recruited from the Imperial Vascular Unit at St Mary's Hospital, Imperial College London by direct approach. All participants finished the study.

RESULTS

Junior surgeons experienced significantly increased sympathetic tone (Low frequency/high frequency (LF/HF) ratio) during team simulation compared to individual simulation (6.01 ± 1.68 vs. 8.32 ± 2.84, p < 0.001). Within team simulation junior surgeons experienced significantly higher heart rate (beats per minute) than their senior counterparts (82 ± 5.83 vs. 76 ± 6.02, p = 0.033). Subjective workload scores (NASA Task Load Index [NASA-TLX]) correlated moderately and significantly with sympathetic tone in surgeons across all stages of simulation. (r = 0.39, p = 0.01).

CONCLUSIONS

A discrete, measurable increase in stress is experienced by surgeons during high-fidelity endovascular simulation and differentially effects junior surgeons. High-fidelity team simulation may have a role to play in improving nontechnical skill, reducing intra-operative stress, and reducing error.

High-Fidelity Endovascular Simulation

With the ongoing changes in graduate medical education, emphasis has been placed on simulation models to increase clinical exposure and optimize learning. In specific, high-fidelity simulation presents as a potential option for procedural-skill development in interventional radiology. With improved haptic, visual, and tactile dynamics, high-fidelity endovascular simulators have gained increasing support from trainees and certified interventionalists alike. The 2 most common high-fidelity endovascular simulators utilized today are the Procedicus VIST and ANGIO Mentor, which contain notable differences in technical features, case availability, and cost. From the perspective of a trainee, high-fidelity simulation allows for the ability to perform a greater volume of cases. Additionally, without the risk of potential harm to the patient, trainees can focus on repetition and improved performance in a stress-free environment. When errors are made, high-fidelity simulator metrics will generate instantaneous feedback and error notification, erasing ambiguity and thus facilitating learning. Furthermore, in an environment devoid of time and cost stressors, the supervising physician is afforded the opportunity to properly mentor and instruct the trainee throughout the case. For the experienced interventionalists, high-fidelity simulation allows for a decreased learning curve for new procedures or techniques, as well as the opportunity for procedure rehearsal for unusual or high-risk cases. Despite the limitations created by cost, high-fidelity endovascular simulation should continue to be increasingly utilized in the development of the interventional radiology curriculum.

Video motion analysis in live coronary angiography differentiates levels of experience and provides a novel method of skill assessment

AIMS

Video motion analysis (VMA) uses fluoroscopic sequences to derive catheter and guidewire movement, and is able to calculate 2D catheter-tip path length (PL) on the basis of frame-by-frame pixel coordinates. The objective of this study was to validate VMA in coronary angiography as a method of skill assessment.

METHODS AND RESULTS

Forty-seven coronary interventions performed by 10 low- (<1,000 cases; group A), five medium- (1,000-4,000; group B) and six high- (>4,000; group C) experience-volume cardiologists were prospectively recorded and analysed using VMA software. Total PL was calculated and procedure, fluoroscopy times, and radiation dose were recorded. Comparisons of PL were made between groups of experience. Groups A, B and C performed 24, 14 and 6 paired (right and left coronary) cannulations, respectively. Calculation of PL was possible in all recorded cases and significantly correlated with procedure (p=<0.001, rho=0.827) and fluoroscopy times (p=<0.001, rho=0.888). Median total path length (combined right and left coronaries) was significantly shorter in group C which used 3,836 pixels of movement (IQR: 3,003-4,484) vs. 10,556 (7,242-31,408) in group A (p=<0.001) and 8,725 (5,187-15,150) in group B (p=0.013).

CONCLUSIONS

VMA in coronary angiography is feasible and PL is able to differentiate levels of experience.

Distributed Simulation as a modelling tool for the development of a simulation-based training programme for cardiovascular specialties

AIMS AND BACKGROUND

Distributed Simulation is the concept of portable, high-fidelity immersive simulation. Here, it is used for the development of a simulation-based training programme for cardiovascular specialities. We present an evidence base for how accessible, portable and self-contained simulated environments can be effectively utilised for the modelling, development and testing of a complex training framework and assessment methodology. Iterative user feedback through mixed-methods evaluation techniques resulted in the implementation of the training programme.

APPROACH

Four phases were involved in the development of our immersive simulation-based training programme: (1) initial conceptual stage for mapping structural criteria and parameters of the simulation training framework and scenario development (n = 16), (2) training facility design using Distributed Simulation, (3) test cases with clinicians (n = 8) and collaborative design, where evaluation and user feedback involved a mixed-methods approach featuring (a) quantitative surveys to evaluate the realism and perceived educational relevance of the simulation format and framework for training and (b) qualitative semi-structured interviews to capture detailed feedback including changes and scope for development. Refinements were made iteratively to the simulation framework based on user feedback, resulting in (4) transition towards implementation of the simulation training framework, involving consistent quantitative evaluation techniques for clinicians (n = 62). For comparative purposes, clinicians' initial quantitative mean evaluation scores for realism of the simulation training framework, realism of the training facility and relevance for training (n = 8) are presented longitudinally, alongside feedback throughout the development stages from concept to delivery, including the implementation stage (n = 62).

FINDINGS

Initially, mean evaluation scores fluctuated from low to average, rising incrementally. This corresponded with the qualitative component, which augmented the quantitative findings; trainees' user feedback was used to perform iterative refinements to the simulation design and components (collaborative design), resulting in higher mean evaluation scores leading up to the implementation phase.

CONCLUSIONS

Through application of innovative Distributed Simulation techniques, collaborative design, and consistent evaluation techniques from conceptual, development, and implementation stages, fully immersive simulation techniques for cardiovascular specialities are achievable and have the potential to be implemented more broadly.

Evidence for Endovascular Simulation Training: A Systematic Review

BACKGROUND

Simulation training in endovascular surgery provides opportunities for trainees to practice and learn from non-patient based experience. Several types of endovascular simulators are available commercially. Previous studies on endovascular simulation training can be categorized into trials in which only a simulator was used when measuring performance metrics or "trials within simulation"; patient specific procedure rehearsals; and randomized, controlled trials (RCTs) or translational studies.

OBJECTIVES

To examine whether endovascular simulation training can improve surgeon techniques and patient outcomes in real clinical settings.

METHODS

A literature review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. All searches were done via PubMed and Embase. Review articles, and papers that were not related to endovascular surgery and not within the scope of interest were excluded. References of review articles were further screened according to the exclusion criteria.

RESULTS

In total, 909 records were identified and 290 duplicates were removed. Thirty-one were included in the qualitative analysis. Twenty-three were trials within simulation and most of them found statistically significant improvements in procedure time, fluoroscopy time, and contrast volume. Five were patient specific procedure rehearsals and showed that simulation significantly affected the fluoroscopy angle and improved performance metrics. Three were RCTs and revealed mainly positive results on a Global Rating Scale and procedure specific rating scale.

CONCLUSIONS

Contemporary evidence shows that performance metrics within endovascular simulations improve with simulation training. Successful translation to in vivo situations is observed in patient specific procedure rehearsals and RCTs on real procedures. However, there is no level I evidence to show that predictive validity of simulation can definitively improve patient outcomes. Current literature supports the idea that there is a beneficial role of simulation in endovascular training. Future studies are needed to confirm the efficacy of simulation in endovascular surgical training and to see if simulation is superior to traditional training in the operating theatre.

Training effect of a virtual reality haptics-enabled dynamic hip screw simulator

BACKGROUND AND PURPOSE

Virtual reality (VR) simulation offers a safe, controlled, and effective environment to complement training but requires extensive validation before it can be implemented within the curriculum. The main objective was to assess whether VR dynamic hip screw (DHS) simulation has a training effect to improve objective performance metrics.

PATIENTS AND METHODS

52 surgical trainees who were naïve to DHS procedures were randomized to 2 groups: the training group, which had 5 attempts, and the control group, which had only one attempt. After 1 week, both cohorts repeated the same number of attempts. Objective performance metrics included total procedural time (sec), fluoroscopy time (sec), number of radiographs (n), tip-apex distance (TAD; mm), attempts at guide-wire insertion (n), and probability of cut-out (%). Mean scores (with SD) and learning curves were calculated. Significance was set as p < 0.05.

RESULTS

The training group was 68% quicker than the control group, used 75% less fluoroscopy, took 66% fewer radiographs, had 82% less retries at guide-wire insertion, achieved a reduced TAD (by 41%), had lower probability of cut-out (by 85%), and obtained an increased global score (by 63%). All these results were statistically significant (p < 0.001). The participants agreed that the simulator provided a realistic learning environment, they stated that they had enjoyed using the simulator, and they recognized the need for the simulator in formal training.

INTERPRETATION

We found a significant training effect on the VR DHS simulator in improving objective performance metrics of naïve surgical trainees. Patient safety, an important priority, was not compromised.

National Simulation-Based Training of Fellows: The Vascular Surgery Example

Vascular surgery has evolved dramatically as a specialty, with new training paradigms and an ever-developing, technically demanding field. The ability to evaluate trainees on their fundamental skills is an important step in ensuring some uniformity in trainees' basic technical abilities. This article describes the development and implementation of the fundamentals of vascular and endovascular surgery, including lessons applied from the Fundamentals of Laparoscopic Surgery and Fundamentals of Endoscopic Surgery programs.

Endovascular versus Non-Interventional Therapy for Cervicocranial Artery Dissection in East Asian and Non-East Asian Patients: a Systematic Review and Meta-analysis

Endovascular methods have been increasingly applied in treating cervicocranial artery dissection (CCAD). Anti-thrombotic therapy, which is used in non-interventional care of CCAD patients, has differential effects in East Asian patients. Therefore, we aimed to compare the clinical outcomes of endovascular versus non-interventional therapy for CCAD in East Asians and non-East Asians. A search was performed for studies comparing endovascular and non-interventional approaches to CCAD patients. Rates of recovery, disability, and mortality were used to assess these approaches in East Asian and non-East Asian patients. Subgroup analyses were conducted for CCAD patients with ruptured dissections. Eleven East Asian studies and five non-East Asian studies were included. The subgroup analyses for CCAD patients with ruptured dissections on mortality (East Asian odds ratio [OR] [95% confidence interval [CI]]: 0.24 [0.08-0.71], P = 0.01; I² = 34%) and good recovery (East Asian OR [95% CI]: 3.79 [1.14-12.60], P = 0.03; I² = 54%) revealed that endovascular therapy is significantly superior to non-interventional therapy for East Asians. No differences in treatment effect upon mortality, disability, or good recovery outcomes were found for the CCAD populations-at-large nor for non-East Asian CCAD patients with ruptured dissections. Endovascular therapy appears to be superior to non-interventional therapy for East Asian CCAD patients with ruptured dissections.

Virtual reality simulation for the optimization of endovascular procedures: current perspectives

Endovascular technologies are rapidly evolving, often requiring coordination and cooperation between clinicians and technicians from diverse specialties. These multidisciplinary interactions lead to challenges that are reflected in the high rate of errors occurring during endovascular procedures. Endovascular virtual reality (VR) simulation has evolved from simple benchtop devices to full physic simulators with advanced haptics and dynamic imaging and physiological controls. The latest developments in this field include the use of fully immersive simulated hybrid angiosuites to train whole endovascular teams in crisis resource management and novel technologies that enable practitioners to build VR simulations based on patient-specific anatomy. As our understanding of the skills, both technical and nontechnical, required for optimal endovascular performance improves, the requisite tools for objective assessment of these skills are being developed and will further enable the use of VR simulation in the training and assessment of endovascular interventionalists and their entire teams. Simulation training that allows deliberate practice without danger to patients may be key to bridging the gap between new endovascular technology and improved patient outcomes.

The use of simulation in neurosurgical education and training

Object

There is increasing evidence that simulation provides high-quality, time-effective training in an era of resident duty-hour restrictions. Simulation may also permit trainees to acquire key skills in a safe environment, important in a specialty such as neurosurgery, where technical error can result in devastating consequences. The authors systematically reviewed the application of simulation within neurosurgical training and explored the state of the art in simulation within this specialty. To their knowledge this is the first systematic review published on this topic to date.

Methods

The authors searched the Ovid MEDLINE, Embase, and PsycINFO databases and identified 4101 articles; 195 abstracts were screened by 2 authors for inclusion. The authors reviewed data on study population, study design and setting, outcome measures, key findings, and limitations.

Results

Twenty-eight articles formed the basis of this systematic review. Several different simulators are at the neurosurgeon's disposal, including those for ventriculostomy, neuroendoscopic procedures, and spinal surgery, with evidence for improved performance in a range of procedures. Feedback from participants has generally been favorable. However, study quality was found to be poor overall, with many studies hampered by nonrandomized design, presenting normal rather than abnormal anatomy, lack of control groups and long-term follow-up, poor study reporting, lack of evidence of improved simulator performance translating into clinical benefit, and poor reliability and validity evidence. The mean Medical Education Research Study Quality Instrument score of included studies was 9.21 ± 1.95 (± SD) out of a possible score of 18.

Conclusions

The authors demonstrate qualitative and quantitative benefits of a range of neurosurgical simulators but find significant shortfalls in methodology and design. Future studies should seek to improve study design and reporting, and provide long-term follow-up data on simulated and ideally patient outcomes.

Endovascular repair of ruptured abdominal aortic aneurysm: technical and team training in an immersive virtual reality environment

PURPOSE

This study evaluates a fully immersive simulated angiosuite for training and assessment of technical endovascular and human factor skills during a crisis scenario.

MATERIALS AND METHODS

Virtual reality (VIST-C, Mentice) simulators were integrated into a simulated angiosuite (ORCAMP, Orzone). Teams, lead by experienced (N = 5) or trainee (N = 5) endovascular specialists, performed simulated endovascular ruptured aortic aneurysm repair (rEVAR). Timed performance metrics were recorded as surrogate measures of performance. Participants (N = 22) completed postprocedure questionnaires evaluating face validity, as well as technical and human factor aspects, of the simulation on a Likert scale from 1 (not at all) to 5 (very much).

RESULTS

Experienced team leaders were significantly faster than trainees in obtaining proximal control with an intra-aortic occlusion balloon (352 vs. 501 s, p = 0.047) and all completed the procedure within the allotted time, whilst no trainee was able to do so. Total fluoroscopy times were significantly lower in the experienced group (782 vs. 1,086 s, p = 0.016). Realism of the simulated angiosuite was scored highly by experienced team leaders (median 4/5, IQR 4-5). Participants found the simulation useful for acquiring technical (4/5, IQR 4-5) and communication skills (4/5, IQR 4-5) and particularly valuable for enhancing teamwork (5/5, IQR 4-5) and patient safety (5/5, IQR 4-5).

CONCLUSION

This study shows feasibility of creation of a crisis scenario in a fully immersive angiosuite simulation and team performance of a simulated rEVAR. Performance metrics differentiated between experienced specialists and trainees, and the realism of the simulation exercise and environment were rated highly by experienced endovascular specialists. This simulation has potential as a powerful training and assessment tool with opportunities to improve team performance in rEVAR through both technical and human factor skills training.

Experience With a Simulator-Based Angiography Course for Neurosurgical Residents

BACKGROUND:

Simulation is an increasingly useful means of teaching in the era of duty hour restrictions. Since the completion of our diagnostic cerebral angiography simulator curriculum pilot program, we have performed this resident course at 2 Congress of Neurological Surgeons (CNS) annual meetings with larger participant numbers.

OBJECTIVE:

To report the ongoing results of these courses.

METHODS:

A 120-minute simulator-based training course was performed at 2 CNS annual meetings. Precourse written and simulator skills assessments were performed, followed by instructor-guided training on an endovascular simulator. Postcourse written and simulator practical assessments were then performed and compared with precourse scores.

RESULTS:

Thirty-seven neurosurgery resident participants completed the course module: 16 completed the first course provided and 21 completed the second. Posttest written scores were significantly higher than pretest scores (mean ± SEM, 8.5 ± 0.40.3 vs 4.9 ± 0.3; P &lt; .001). Instructor assessments of practical posttest scores of participants were significantly higher than pretest practical scores for both the CNS 2011 and CNS 2012 groups (P &lt; .001).

CONCLUSION:

The expansion of a curriculum-based, cerebral angiography simulator pilot program to trainees through courses at national neurosurgical meetings demonstrated excellent results with significant improvements in written test scores and instructor assessments of participant technical skills. With ever-expanding improvements in simulation technology and realism, simulator training for cerebral angiography may become an integral component of resident training in the future.

Impact of an intensive 2-day endovascular training course on technical performance of trainees

BACKGROUND

The objective of this study was to evaluate the effect of a 2-day international endovascular training course on the performance of trainees as compared with a control group, assessed in a bench model-based task using an objective structured evaluation protocol.

METHODS

A total of 50 trainees, 28 course participants of 2 consecutive identical courses and a control group of 22 participants with a similar level of experience without course attendance, underwent baseline and final assessment (simulated arterial access task). The evaluation form consisted of a global assessment (GA), task-specific checklist percentage score (CL), and global rating scale percentage score (GR), with both percentage scores ranging from 0% (worst performance) to 100% (best performance).

RESULTS

Course participants were more likely to pass the GA at final testing than the control group (odds ratio=59; 95% confidence interval [CI] 9.5-656; P<0.001). The estimated difference in percentage score at final testing between course participants and the control group was 26% (95% CI 18-34; P<0.001) for the CL and 29% (95% CI 19-40; P<0.001) for the GR.

CONCLUSIONS

A 2-day structured endovascular training course significantly improves endovascular performance in a simulated environment. These results are important for the design of endovascular training curricula with the ultimate goal of contributing to patient safety.

Objective simulator-based evaluation of carotid artery stenting proficiency (from Assessment of Operator Performance by the Carotid Stenting Simulator Study [ASSESS])

Studies have suggested that operator proficiency has a substantial effect on complication rates and procedural outcomes. Endovascular simulators have been used for training and have been proposed as an alternative to the conventional assessment of skills. The present study sought to validate simulation as an objective method for proficiency evaluation in carotid artery stenting. Interventional cardiologists classified as novice, intermediate, or experienced practitioners performed 3 simulated, interactive carotid stenting cases on an AngioMentor endovascular simulator. An automated algorithm scored the participants according to the technical performance, medical management, and angiographic results. A total of 33 interventional cardiologists (8 novices, 15 intermediates, and 10 experts) completed 82 simulated procedures. The composite scores for the case simulations varied significantly by operator experience, with better scores for the more experienced groups (p <0.0001). The metrics that discriminated between operator experience groups included fluoroscopy time, crossing the carotid lesion with devices other than a 0.014-in. wire before filter deployment, and incomplete coverage of the lesion by the stent. In conclusion, the results of the present study validate that a simulator with an automated scoring system is able to discriminate between levels of operator proficiency for carotid artery stenting. Simulator-based performance assessment could have a role in initial and ongoing proficiency evaluations and credentialing of interventional operators of high-risk endovascular procedures.

Simulation and augmented reality in endovascular neurosurgery: lessons from aviation

Endovascular neurosurgery is a discipline strongly dependent on imaging. Therefore, technology that improves how much useful information we can garner from a single image has the potential to dramatically assist decision making during endovascular procedures. Furthermore, education in an image-enhanced environment, especially with the incorporation of simulation, can improve the safety of the procedures and give interventionalists and trainees the opportunity to study or perform simulated procedures before the intervention, much like what is practiced in the field of aviation. Here, we examine the use of simulators in the training of fighter pilots and discuss how similar benefits can compensate for current deficiencies in endovascular training. We describe the types of simulation used for endovascular procedures, including virtual reality, and discuss the relevant data on its utility in training. Finally, the benefit of augmented reality during endovascular procedures is discussed, along with future computerized image enhancement techniques.

Carotid Artery Stenting - Strategies to Improve Procedural Performance and Reduce the Learning Curve

Carotid artery stenting (CAS) remains an appealing intervention to reduce the stroke risk because of its minimal invasive nature. Nevertheless, landmark randomised controlled trials have not been able to resolve the controversies surrounding this complex procedure as the peri-operative stroke risk in a non-selected patient population still seems to be higher after CAS in comparison to carotid endarterectomy. What is more, these trials have highlighted that patient outcome after CAS is influenced by patient- and operator-dependant factors. The CAS procedure exhibits a definitive learning curve resulting in higher complication rates if the procedure is performed by inexperienced interventionists or in low-volume centres. This article will outline strategies to improve the performance of physicians carrying out the CAS procedure by means of proficiency-based training, credentialing, virtual reality rehearsal and optimal patient selection.

Advanced catheter technology: is this the answer to overcoming the long learning curve in complex endovascular procedures

INTRODUCTION

Advanced endovascular procedures require a high degree of skill with a long learning curve. We aimed to identify differential increases in endovascular skill acquisition in novices using conventional (CC), manually steerable (MSC) and robotic endovascular catheters (RC).

MATERIALS/METHODS

10 novices cannulated all vessels within a CT-reconstructed pulsatile-flow arch phantom in the Simulated Endovascular Suite. Subjects were randomly assigned to conventional/manually-steerable/robotic techniques as the first procedure undertaken. The operators repeated the task weekly for 5 weeks. Quantitative (cannulation times, wire/catheter-tip movements, vessel wall hits) and qualitative metrics (validated rating scale (IC3ST)) were compared.

RESULTS

Subjects exhibited statistically significant differences when comparing initial to final performance for total procedure times and catheter-tip movements with all catheter types. Sequential non-parametric comparisons identified learning curve plateau levels at weeks 2 or 3(RCs, MSCs), and at week 4(CCs) for the majority of metrics. There were significantly fewer catheter-tip movements using advanced catheter technology after training (Week 5: CC 74 IQR(59-89) versus MSC 62(44-81); p = 0.028, and RC 33 (28-44); p = 0.012). RCs virtually eliminated wall hits at the arch (CC 29(28-76) versus RC 8(6-9); p = 0.005) and produced significantly higher overall performance scores (p < 0.02).

CONCLUSION

Advanced endovascular catheters, although more intricate, do not seem to take longer to master and in some areas offer clear advantages with regards to positional control, at a faster rate. RCs seem to be the most intuitive and advanced skill acquisition occurs with minimal training. Robotic endovascular technology may have a significantly shorter path to proficiency allowing an increased number of trainees to attempt more complex endovascular procedures earlier and with a greater degree of safety.

Carotid Artery Stenting: Relationship between Experience and Complication Rate

To investigate the evidence for the relationship between volume and outcome for carotid artery stenting. We performed a systematic review of the literature to examine the influence of experience and/or volume on outcome for carotid artery stenting. The primary search strategy was to identify studies presenting year-on-year data. The Pubmed, Embase, Medline and the Cochrane Collaboration databases were searched. Studies with over 100 interventions were included. The main outcome measure compared across studies was all stroke/death. Where possible, comparable data were pooled and analysed using meta-regression techniques. It was not possible to perform a standard systematic review and meta-analysis because of the lack of data from randomised studies. When redundant studies were excluded, four sizeable case series and one registry met the inclusion criteria. When the case series results were pooled, the χ2-test for trend demonstrated a significant reduction in the combined stroke and death rate over time. Meta-regression analysis of case series data allowed the setting of thresholds for ‘acceptable’ stroke/death rates. Where year-on-year data are available, published stroke and death rates for carotid artery stenting show improvements over time. While advances in technology and pharmacology may in part be responsible, temporal improvement in outcomes demonstrated in both early and contemporary time-frames together with the consistency of the results suggests the presence of a learning curve. In active carotid artery stenting units, it may take almost 2-years before the stroke/death rates fall below an arbitrary 5% threshold.

Patient-specific simulation in carotid artery stenting

AIMS

Patient-specific virtual reality (VR) simulation is a technologic advancement that allows planning and practice of the carotid artery stenting (CAS) procedure before it is performed on the patient. The initial findings are reported, using this novel VR technique as a tool to optimize technical and nontechnical aspects of this complex endovascular procedure.

METHODS

In the angiography suite, the same interventional team performed the VR rehearsal and the actual CAS on the patient. All proceedings were recorded to allow for video analysis of team, technical, and nontechnical skills.

RESULTS

Analysis of both procedures showed identical use of endovascular tools, similar access strategy, and a high degree of similarity between the angiography images. The total procedure time (24.04 vs 60.44 minutes), fluoroscopy time (11.19 vs 21.04 minutes), and cannulation of the common carotid artery (1.35 vs 9.34) took considerably longer in reality. An extensive questionnaire revealed that all team members found that the rehearsal increased the subjective sense of teamwork (4/5), communication (4/5), and patient safety (4/5).

CONCLUSION

A VR procedure rehearsal is a practical and feasible preparatory tool for CAS and shows a high correlation with the real procedure. It has the potential to enhance the technical, nontechnical, and team performance. Further research is needed to evaluate if this technology can lead to improved outcomes for patients.