Simon Neequaye

Cognitive training improves clinically relevant outcomes during simulated endovascular procedures

OBJECTIVES Virtual reality (VR) simulation has been suggested to objectively assess endovascular skills. The aim of this study was to determine the impact of cognitive training on technical performance of inexperienced subjects on a commercially available VR simulator (VIST, Vascular Intervention Simulation Trainer, Mentice, Gothenburg, Sweden). METHODS Forty-seven subjects treated an identical virtual iliac artery stenosis endovascularly. Surgical trainees without endovascular experience were allocated to two training protocols: group A(1) (n = 10) received a 45 minute didactic session followed by an expert demonstration of the procedure that included error-based learning, whereas group A(2) (n = 10) was only given a demonstration of an iliac dilation and stent procedure. All trainees performed the intervention immediately following the expert demonstration. Twenty-seven endovascular physicians were recruited (>100 endovascular interventions). Performance was assessed using the quantitative (procedure and fluoroscopy time) and qualitative (stent/vessel ratio and residual stenosis) assessment parameters recorded by the simulator. RESULTS The end-product (qualitative metrics) in the cognitive-skills group A(1) was similar to those of the endovascular physicians, though A(2) performed significantly worse than the physicians (group B): stent/vessel ratio (A(1) 0.89 vs B 0.96, P = .960; A(2) 0.66 vs B 0.96, P = .001) and residual stenosis (A(1) 11 vs B 4%, P = .511; A(2) 35 vs B 4%, P < .001). Group A(1) took longer to perform the procedure (A(1) 982 vs B 441 seconds, P < .001), with greater use of fluoroscopy than group B (A(1) 609 vs B 189 seconds, P < .001) whereas group A(2) performed the intervention as quickly as group B (A(2) 358 vs B 441 seconds, P = .192) but used less fluoroscopy (A(2) 120 vs 189 seconds, P = .002). CONCLUSION Cognitive-skills training significantly improves the quality of end-product on a VR endovascular simulator, and is fundamental prior to assessment of inexperienced subjects.

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

OBJECTIVE Carotid artery stenting (CAS) is an advanced endovascular intervention with a steep learning curve. Virtual reality (VR) simulation has been proposed as a means to train and objectively assess technical performance. AIM To objectively assess psychomotor skills acquisition of experienced interventionalists attending a two-day CAS course, using a VR simulator. METHODS Both cognitive and technical skills of 11 interventionalists were trained in a two-day course using didactic sessions, case reviews, supervised VR simulation and live-cases. Pre- and post-course skills were assessed through performance on the same CAS procedure using metrics derived from the simulator. RESULTS Significant differences were noted between pre- and post-course performance for procedure (36 vs. 20min., p=0.005), X-ray (20 vs. 11min., p=0.016) and delivery-retrieval time of the embolic protection device (12 vs. 9min., p=0.007). Advancement of the guiding catheter without a leading wire occurred to a greater extent pre- versus post-course (199 vs. 152mm., p=0.050) as did spasm of the internal carotid artery (4 vs. 2, p=0.049). CONCLUSIONS This study has objectively proven a benefit for experienced interventionalists to attend CAS courses for skills acquisition measured by a VR simulator. These data can be used to offer participants an insight into their skills and objectively audit course efficacy.

Evaluating training for a simulated team in complex whole procedure simulations in the endovascular suite

Introduction: Simulators supporting the development of technical skills for complex procedures are gaining prominence. Safe performance of complex procedures requires effective team interactions. Our research group creates ‘whole’ procedure simulations to produce the psychological fidelity of clinical settings. Recruitment of real interventional team (IT) members has proved challenging. Actors as a simulated team are expensive. We hypothesised that medical students and trainees in a vascular unit could authentically portray members of the endovascular suite for carotid stenting. Methods: This paper describes the evaluation of a training programme for a simulated IT. Participants rated the extent to which programmes objectives were met and realism of simulations. Researchers’ field notes provided insight into strengths and weaknesses of the programme. Results: Seven members from the vascular unit undertook training. Learning objectives were largely met. Nineteen simulations with 13 interventionalists were performed. Realism levels were at least moderate. Simulated IT members reported increased understanding of teamwork and roles in the endovascular suite. Discussion: A simulated IT proved feasible. Authentic psychological fidelity complemented the physical fidelity of the simulated suite. Although there were areas for development in training, this approach might contribute considerably to interventionalist training and increase knowledge and skills of vascular trainees and medical students.

Sheath-shunt technique for avoiding lower limb ischemia during complex endovascular aneurysm repair

Complex aortic aneurysms are now being repaired by endovascular techniques, albeit with a potentially increased risk of lower limb ischemia-reperfusion injury. We report a simple technique to maintain perfusion to the lower limb during endovascular repair, using one additional introducer sheath placed antegrade, distal to the stent graft introduction site, and connected to the side arm of the working sheath in the contralateral artery. This allows continuous perfusion of the limb distal to the main stent graft introduction site. In our initial experience with 12 cases, with confirmed occlusion of the native arterial system by the stent graft introducer sheath, arterial occlusion time was 165 ± 84 minutes. Use of the sheath-shunt technique resulted in pulsatile flow in all cases, with an average flow of 42.2 ± 13.2 mL/min, and actual ischemia time was reduced to 14 ± 11 minutes. There were no complications related to the use of this technique. Given the limited risk of this technique coupled with a potential benefit, we propose its consideration in patients undergoing complex endovascular repair.