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

Combined sterno-clavicular approach as an alternative technique in hybrid exclusion of aortic arch aneurysm

<p>Abstract</p> <p>Background</p> <p>We describe a modified access technique for the proximal (open) part of single stage hybrid exclusion of aneurysm of the aortic arch.</p> <p>Case presentation</p> <p>3 patients had a bifurcated Dacron graft for the innominate and left subclavian arteries and an additional end-to-side anastomosis of the left common carotid artery on the limb to the left subclavian artery. With our modification, access to the left subclavian artery is by left subclavicular incision and creation of an anterior tunnel via the left thoracic outlet from the origin of the left subclavian artery along its anatomical course to the subclavicular plane.</p> <p>Discussion</p> <p>Advantages and disadvantages of this technique in relation to anatomy and pathology.</p

Visuospatial and psychomotor aptitude predicts endovascular performance of inexperienced individuals on a virtual reality simulator

Objectives: This study evaluated virtual reality (VR) simulation for endovascular training of medical students to determine whether innate perceptual, visuospatial, and psychomotor aptitude (VSA) can predict initial and plateau phase of technical endovascular skills acquisition. Methods: Twenty medical students received didactic and endovascular training on a commercially available VR simulator. Each student treated a series of 10 identical noncomplex renal artery stenoses endovascularly. The simulator recorded performance data instantly and objectively. An experienced interventionalist rated the performance at the initial and final sessions using generic (out of 40) and procedure-specific (out of 30) rating scales. VSA were tested with fine motor dexterity (FMD, Perdue Pegboard), psychomotor ability (minimally invasive virtual reality surgical trainer [MIST-VR]), image recall (Rey-Osterrieth), and organizational aptitude (map-planning). VSA performance scores were correlated with the assessment parameters of endovascular skills at commencement and completion of training. Results: Medical students exhibited statistically significant learning curves from the initial to the plateau performance for contrast usage (medians, 28 vs 17 mL, P < .001), total procedure time (2120 vs 867 seconds, P < .001), and fluoroscopy time (993 vs. 507 seconds, P < .001). Scores on generic and procedure-specific rating scales improved significantly (10 vs 25, P < .001; 8 vs 17 P < .001). Significant correlations were noted for FMD with initial and plateau sessions for fluoroscopy time (r(s) = -0.564, P = .010; r(s) = -.449, P = .047). FMD correlated with procedure-specific scores at the initial session (r(s) = .607, P = .006). Image recall correlated with generic skills at the end of training (r(s) = .587, P = .006). Conclusions: Simulator-based training in endovascular skills improved performance in medical students. There were significant correlations between initial endovascular skill and fine motor dexterity as well as with image recall at end of the training period. In addition to current recruitment strategies, VSA may be a useful tool for predictive validity studies

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

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

Skills training after night shift work enables acquisition of endovascular technical skills on a virtual reality simulator

Background: Adoption of residents' working time restrictions potentially undermines surgical training by reduction of operating room exposure. Simulation has been proposed as a way to acquire necessary skills in a laboratory environment but remains difficult to incorporate into training schedules. This study assessed whether residents working successive nights could acquire endovascular skills similar to colleagues working day shifts. Methods: This prospective observational cohort study recruited 20 junior residents, divided into day shift and night shift groups by their respective call schedule. After initial cognitive skills training, a validated renal artery stent module on an endovascular simulator was completed over a series of seven sequential shifts during 1 week. The primary outcome measure was serial technical skill assessments. Secondary measures comprised assessments of activity, cognitive performance, introspective fatigue, quality, and quantity of preceding sleep. Results: Both groups demonstrated significant learning curves for total time at the first session median vs seventh session median (181 vs 564 seconds [P <.001]; night, 1399 vs 572 [P <.001]), fluoroscopy time (day, 702 vs 308 seconds, [P <.001]; night, 669 vs 313 [P <.001]), and contrast volume (day, 29 vs 13 mL [P <.001]; night, 40 vs 16 [P <.001]). Residents working day shifts reached plateau 1 day earlier in the above measures vs those on night duty. The night shift group walked more steps (P <.001), reviewed more patients (P <.001), performed worse on all cognitive assessments (P <.05), slept less (P <.05), had poorer quality of sleep (P=.001), and was more fatigued (P <.001) than the day shift group. Acquired skill was retained a week after completion of shifts. Conclusion: Technical skills training after night shift work enables acquisition of endovascular technical skills, although it takes longer than after day shift training. This study provides evidence for program directors to organize simulation-based training schedules for residents on night shift rotations