A Multicentre Trial of Patient specific Rehearsal Prior to EVAR: Impact on Procedural Planning and Team Performance

Simulation to Scalpel: A Systematic Review of True Evidence of Skills Transfer as Seen Through the Lens of Patient Outcomes

INTRODUCTION

Simulation-based training (SBT) has become an essential component of surgical education. However, the definitive evidence for dissrect patient outcomes remains inconsistent. This prompted us to conduct this systematic review and meta-analysis to evaluate Kirkpatrick Level 4 evidence on whether SBT translates into clinical benefits and improves patient outcomes.

METHODS

We designed a search protocol a priori and followed PRISMA guidelines for systematic reviews. Medline (via PubMed), Cochrane Library, online clinical trial registers, and websites were reviewed from their inception until 31st October 2024. Included studies were randomized controlled trials with patients undergoing any invasive intervention involving manual skills after SBT compared to the same intervention involving manual skills without SBT and comparing Clavien-Dindo complication grades. The methodological quality of included studies was assessed using the Cochrane's revised tool to assess the risk of bias in randomized trials. The Cochrane Collaboration's Review Manager software version 5.3 was utilized for data analysis. The grading of recommendation, assessment, development, and evaluation (GRADE) instrument was used for recommendation strength in the included studies in the meta-analysis.

RESULTS

Ten studies were included in the final meta-analysis; all were rated as low risk of bias. The results favored simulation, but no statistically significant difference was observed between simulation and conventional training. The GRADE assessment reflected moderate certainty.

DISCUSSION

We evaluated the effectiveness of simulation-based training (SBT) in improving patient-centric outcomes, classified by Clavien-Dindo complication grades using Kirkpatrick Level 4 evidence from randomized controlled trials, and discovered that results were comparable to traditional training. Future studies are needed to address this limitation in the current evidence base for simulation-based training to confirm and maximize its patient-centered benefits.

The Impact of Surgeon Experience-Consultant Versus Supervised Trainees After Elective Infrarenal EVAR: Short-term to Mid-term Outcomes

INTRODUCTION

Vascular trainees are required to have a comprehensive training program, encompassing the completion of clinical, surgical, and research tasks. To fulfill their surgical abilities and performance, sufficient supervised operating time is mandatory. After open vascular procedures, it has been observed that trainee involvement does not lead to detrimental outcomes. On the contrary, its impact during endovascular procedures, which require distinct technical skills, is scarcely reported. The authors aim to analyze the impact of primary operator experience on the outcomes of elective infrarenal endovascular aneurysm repair (EVAR) performed within a teaching institution over a 14-year period.

METHODS

This is a single-center, retrospective, comparative study. All consecutive patients submitted to elective EVAR (2011-2023) were considered. Two groups were defined: supervised trainee (ST) and consultant (C), according to the experience of the primary operator. The primary outcome was the incidence of 30-day major adverse events (MAEs). The secondary outcomes were contrast usage, operative time, bleeding, length of stay (LOS), return to operating room (OR), and freedom from aortic-related interventions up to 2 years.

RESULTS

Overall, 507 patients were included (62.1% ST vs 32.5% C). Seventy-two MAEs occurred in 8.1%, with no differences across groups (7.0% ST vs 9.9% C, p=0.31, adjusted odds ratio [aOR]=0.94, 95% confidence interval [CI]=0.46-1.91 for ST-performed procedures), even when MAE components were depicted individually. After adjustment for confounders, no significant differences were found in contrast usage ≥120 mL (aOR=0.89, 95% CI=0.50-1.56), operative time ≥160 minutes (aOR=0.73, 95% CI=0.45-0.18), bleeding (aOR=1.13, 95% CI=0.60-2.12), intensive care unit admission (aOR=0.68, 95% CI=0.40-1.17), prolonged LOS (aOR=0.93, 95% CI=0.60-1.43), return to OR (aOR=0.91, 95% CI=0.37-2.20), and mid-term freedom from aortic-related interventions (adjusted hazard ratio [aHR]=1.39, 95% CI=0.69-2.79).

CONCLUSION

In carefully selected cases, elective EVAR performed by supervised trainees seems as safe and effective at mid-term as operations performed by consultants. These findings may have important implications for training programs. Further studies to confirm and clarify our findings are required.

CLINICAL IMPACT

In carefully selected cases, elective EVAR performed by supervised trainees seems safe, when compared to operations performed by consultants. Short-term major adverse events, contrast usage, operative time, bleeding, secondary interventions and length of stay appear similar. Mid-term freedom-from aortic interventions is comparable. These findings may have important implications for vascular training programs.

Certification of Basic Skills in Endovascular Aortic Repair Through a Modular Simulation Course With Real Time Performance Assessment

OBJECTIVE

Endovascular aortic repair (EVAR) is being used increasingly for the treatment of infrarenal abdominal aortic aneurysms. Improvement in educational strategies is required to teach future vascular surgeons EVAR skills, but a comprehensive, pre-defined e-learning and simulation curriculum remains to be developed and tested. EndoVascular Aortic Repair Assessment of Technical Expertise (EVARATE), an assessment tool for simulation based education (SBE) in EVAR, has previously been designed to assess EVAR skills, and a pass limit defining mastery level has been set. However, EVARATE was developed for anonymous video ratings in a research setting, and its feasibility for real time ratings in a standardised SBE programme in EVAR is unproven. This study aimed to test the effect of a newly developed simulation based modular course in EVAR. In addition, the applicability of EVARATE for real time performance assessments was investigated.

METHODS

The European Society of Vascular Surgery (ESVS) and Copenhagen Certification Programme in EVAR (ENHANCE-EVAR) was tested in a prospective cohort study. ENHANCE-EVAR is a modular SBE programme in EVAR consisting of e-learning and hands-on SBE. Participants were rated with the EVARATE tool by experienced EVAR surgeons.

RESULTS

Twenty-four physicians completed the study. The mean improvement in EVARATE score during the course was +11.8 (95% confidence interval 9.8 - 13.7) points (p < .001). Twenty-two participants (92%) passed with a mean number of 2.8 ± 0.7 test attempts to reach the pass limit. Cronbach's alpha coefficient was 0.91, corresponding to excellent reliability of the EVARATE scale. Differences between instructors' EVARATE ratings were insignificant (p = .16), with a maximum variation between instructors of ± 1.3 points.

CONCLUSION

ENHANCE-EVAR, a comprehensive certifying EVAR course, was proven to be effective. EndoVascular Aortic Repair Assessment of Technical Expertise (EVARATE) is a trustworthy tool for assessing performance within an authentic educational setting, enabling real time feedback.

Optimizing Surgical Efficiency in Complex Spine Surgery Using Virtual Reality as a Communication Technology to Promote a Shared Mental Model: A Case Series and Review

BACKGROUND AND OBJECTIVES

Virtual reality (VR) is an emerging technology that can be used to promote a shared mental model among a surgical team. We present a case series demonstrating the use of 3-dimensional (3D) VR models to visually communicate procedural steps to a surgical team to promote a common operating objective. We also review the literature on existing uses of VR for preoperative communication and planning in spine surgery.

METHODS

Narrations of 3 to 4-minute walkthroughs were created in a VR visualization platform, converted, and distributed to team members through text and email the night before surgical intervention. A VR huddle was held immediately before the intervention to refine surgical goals. After the intervention, the participating team members' perceptions on the value of the tool were assessed using a survey that used a 5-point Likert scale. MEDLINE, Google Scholar, and Dimensions AI databases were queried from July 2010 to October 2022 to examine existing literature on preoperative VR use to plan spine surgery.

RESULTS

Three illustrative cases are presented with accompanying video. Postoperative survey results demonstrate a positive experience among surgical team members after reviewing preoperative plans created with patient-specific 3D VR models. Respondents felt that preoperative VR video review was "moderately useful" or more useful in improving their understanding of the operational sequence (71%, 5/7), in enhancing their ability to understand their role (86%, 6/7), and in improving the safety or efficiency of the case (86%, 6/7).

CONCLUSION

We present a proof of concept of a novel preoperative communication tool used to create a shared mental model of a common operating objective for surgical team members using narrated 3D VR models. Initial survey results demonstrate positive feedback among respondents. There is a paucity of literature investigating VR technology as a means for preoperative surgical communication in spine surgery.

ETHICS

Institutional review board approval (IRB-300009785) was obtained before this study.

Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms

OBJECTIVE

The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy.

METHODS

The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence.

RESULTS

A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed.

CONCLUSION

The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.

The Impact of Simulation-Based Training in Cardiovascular Medicine: A Systematic Review

Cardiovascular medicine and practice in recent times have evolved as complex procedures are performed to manage difficult cases. The majority of these interventions are done percutaneously in order to minimize patient risk. Additionally, training specialist in handling these interventions require a lot of exposure to them; as such, patients are at higher risk of errors and complications from trainees before attaining expertise. In order to avoid these possible risks to patients and ensure their safety, using simulation commonly in cardiovascular specialist education is a possible trend in the future. This article aims to review randomized controlled trials that were performed in cardiology and vascular medicine regarding the use of simulating models to transfer skills to trainees. This study is a systematic review that includes publications dated from 2010 from any country and only in English. The search involved several combinations of search terms from medical subject headings (MeSH). Keywords in the title, abstract, and text for the population, intervention, control, and outcomes were first done in a pilot search to establish the sensitivity of the search strategy. Studies were searched in PubMed, Medline, Cochrane Library, Embase, CINAHL, and Hirani. Data were presented in the PRISMA flowchart and tabular form. A total of 389 studies were obtained from five databases using the search strategies. Eighty-nine studies were excluded for duplication. The total number of studies that did not meet the inclusion criteria was 269, and they were excluded based on abstract and title screening. Another 18 studies were excluded based on full-text screening. In this study, 13 articles were selected ranging from 2011 to 2022. The majority of the outcomes of the study demonstrated that simulation tutoring complements traditional methods of training. Countries of publication were the United States of America, Canada, Italy, Korea, California, Ireland, Germany, Belgium, Switzerland, United Kingdom, Netherlands, and France. Procedures simulated include coronary angiography, transseptal catheterization, cardiopulmonary resuscitation, ultrasound-guided radial artery cannulation, diagnostic angiograms, coiled carotid terminus aneurysms in the setting of subarachnoid hemorrhage, middle cerebral artery embolectomies, renal artery angioplasty/stenting, endovascular aneurysm repair, transvenous pacing wire, intra-aortic balloon pump, and pericardiocentesis. Despite the accredited drawback of availability and cost noted with simulation-based education, there is evidence that it offers many advantages compared to traditional teaching methods. From this study, simulation-based teaching has been shown to effectively transfer skills to trainees especially when used as an adjunct to the apprenticeship method. As a result, we recommend that virtual reality education should be integrated with real-life teaching in modern cardiovascular modules as this will help ensure early skill transfer while maintaining patient safety.

Assessing endovascular team performances in a hybrid room using the Black Box system: a prospective cohort study

BACKGROUND

The hybrid room (HR) is a complex, high-risk environment, requiring teams (surgeons, anesthesiologists, nurses, technologists) to master various skills, including the 'As Low As Reasonably Achievable' principle of radiation safety. This prospective single center cohort reports the first use of the Operating Room Black Box (ORBB) in a HR. This medical data recording system captures procedural and audio-visual data to facilitate structured team performance analysis.

METHODS

Patients planned for endovascular repair of an infrarenal abdominal aortic aneurysm (EVAR) or treatment of symptomatic iliac-femoral-popliteal atherosclerotic disease (Peripheral Vascular Interventions or PVI) were included. Validated measures and established assessment tools were used to assess (non-)technical skills, radiation safety performance and environmental distractions.

RESULTS

Six EVAR and sixteen PVI procedures were captured. Technical performance for one EVAR was rated 19/35 on the procedure-specific scale, below the 'acceptable' score of 21. Technical skills were rated above acceptable in all PVI procedures. Shared decision making and leadership were rated highly in 12/22 cases, whereas surgical communication and nurses' task management were rated low in 14/22 cases. Team members rarely stepped back from the C-arm during digital subtraction angiography. Radiation safety behavior was scored below 'acceptable' in 14/22 cases. A median (interquartile range) number of 12 (6-23) auditory distractions was observed per procedure.

CONCLUSIONS

The ORBB facilitates holistic workplace-based assessment of endovascular performance in a HR by combining objective assessment parameters and rating scale-based evaluations. Strengths and weaknesses were identified in team members' (non-)technical and radiation safety practices. This technology has the potential to improve vascular surgical practice, though human input remains crucial. (NCT04854278).

Crisis Preparedness: A Systems-Based Framework for Avoiding Harm in Surgery

BACKGROUND

Highly performing healthcare organizations benefit from robust failure management systems. This involves the ability to respond and recover from critical events, as well avoiding harm in the first place (crisis preparedness). Currently, the surgical community may lack an integrated toolbox for crisis readiness. The study aims to create a practical framework for crisis preparedness in surgery.

STUDY DESIGN

A multimethod qualitative study was designed to identify and translate crisis preparedness interventions from high-reliability industries to clinical practice. The tools and strategies identified were subsequently developed and clinically adapted for healthcare use. The study used (1) observational fieldwork in commercial aviation; (2) semi-structured interviews with senior airline pilots, and (3) mixed focus groups with healthcare and aviation safety experts. A crisis preparedness framework was derived by thematic analysis using the framework method. Clinical adaptation was achieved using expert consensus methodology.

RESULTS

Twenty-two aviation and healthcare experts participated in 17 interviews and 3 focus groups. A framework for crisis preparedness was derived, consisting of 6 behavioral interventions: (1) anticipate threats and errors by building situational awareness using cognitive tools; (2) brief teams about goals, deviations, operational risks, and contingency plans; (3) implement standard operating procedures using checklists; (4) rehearse emergency drills before critical phases of work; (5) set the tone for a positive working environment by establishing cultural norms and empowering individuals to speak up about safety issues; and (6) debrief performance outcomes to derive learning lessons.

CONCLUSIONS

Surgical crisis preparedness requires integrated systems rather than isolated safety interventions. This study provides a framework and the tools to achieve this.

Safety of the endovascular aneurysm repair procedure: real-world evidence using interrupted-time series analysis

OBJECTIVES

In Taiwan, endovascular aneurysm repair for treating abdominal aortic aneurysms (AAA) was introduced in 2004 and became reimbursable in February 2010. We evaluated the real-world practice and safety of endovascular aneurysm repair in Taiwan.

METHODS

Patients who underwent repair operations for AAA (open or endovascular) from 2000 to 2016 were enrolled (n = 11485). Outcome statistics (during the index hospitalization: length of stay, rate of ischaemic bowel disease and 30-day mortality; after discharge: 30-day readmission rate, 2-year mortality, 2-year reintervention rate and 2-year paraplegia rate) were calculated for each half-year cohort. Propensity score-based stabilized weights were used to balance covariates among each half-year cohort. Interrupted time-series analysis was then performed.

RESULTS

The elective and emergency ratio of AAA repair was 50:50 from 2000 to 2004 and became 60:40 from 2010 to 2016. The half-year rate of endovascular aneurysm repair was 0% in 2000 to 2004/06, 83.16% in 2010 and 98.1% in 2016. Interrupted time series analysis revealed that after endovascular aneurysm repair became reimbursable, both elective and emergency groups had a reduction in length of stay (-4.2 days, P < 0.0001; -1.5 days, P = 0.0928) and 30-day mortality (-5.22%, P = 0.0702; -7.76%, P = 0.0086) but a significant increase in the reintervention rate (5.05%, P = 0.0031; 4.36%, P = 0.0097).

CONCLUSIONS

Endovascular aneurysm repair was predominantly used in treating AAAs after it was reimbursed in Taiwan. Endovascular aneurysm repair is efficacious regarding short-term outcomes but increased the 2-year reintervention rate in both groups.

Application of technology to educational needs in surgery

Innovations in surgical education follow advancing clinical technology. New surgical methods have prompted demand for systematic methods to leverage computing power and internet tools to achieve proficiency-based training goals. Virtual reality, high-fidelity patient simulation, web-based resources to facilitate performance assessment, and telementoring have become mainstream practices, although patient outcomes benefits are not well studied. Remote virtual meeting and mentoring have had transformative effects on resident experiences, the full effects of which remain to be seen.

Simulation-Based Virtual-Reality Patient-Specific Rehearsal Prior to Endovascular Procedures: A Systematic Review

Patient-specific rehearsal (PsR) is a new concept whereby a procedure can be rehearsed virtually using the exact patient’s anatomical data prior to performing the real procedure. The aim of this study was to ascertain if endovascular virtual-reality PsR simulation enhanced performance in real life. This was done by performing a systematic review following the preferred reporting items for systematic reviews and meta-analysis (PRISMA) guidelines. A literature search was conducted in PubMed, Embase, The Cochrane Library and Web of Science concerning PsR in endovascular procedures. All publications were handled using Covidence. Reference lists were also screened. Data extracted from the studies were realism rating, procedure time, fluoroscopy time, contrast volume, number of angiograms and reduction of errors. Kirkpatrick’s four-level model for measuring the efficiency of training was used for guidance of the relevance of studies. The search yielded 1155 results after the exclusion of duplicates, and 11 studies were included. Four studies had a control group, including one randomized trial; the remaining seven were feasibility studies. The realism was rated high, and overall, the studies showed improvements in procedure time, fluoroscopy time and contrast volume after PsR. One study assessed and confirmed the reduction in errors after PsR. Only two studies included more than 15 patients in their cohort. Kirkpatrick’s model was applied to all studies, with one study reaching level 4. All studies found the concept of PsR to be feasible and realistic. The studies with a control group showed a reduction of overall procedure time, radiation exposure and potential errors in endovascular procedures following PsR.

Operators believe patient-specific rehearsal improve individual and team performance

INTRODUCTION

Rehearsing endovascular aortic aneurysm repair on patient-specific data is recent within virtual reality simulation and opens up new possibilities for operators to prepare for complex procedures. This study evaluated the feasibility of patient-specific rehearsal (PsR) and assessed operators' appraisal of the VIST-LAB simulator from Mentice.

MATERIAL AND METHODS

CT-data was segmented and uploaded to the simulator, and simulated for 30 elective EVAR patients. Operators were asked how they perceived the PsR on a Likert scale after the PsR (once) and after the following procedure (each time).

RESULTS

Patients were simulated and operated by 14 operators, always in pairs of one vascular surgeon and one interventional radiologist. The operators estimated that PsR improved individual and team performance (median 4), and recommended the use of PsR in general (median 4) and for difficult cases (median 5). The simulator realism got moderate scores (median 2-3). Inexperienced operators seemed to appreciate the PsR the most.

CONCLUSIONS

PsR was feasible and was evaluated by operators to improve individual and team performance. Inexperienced users were more positive towards PsR than experienced users. PsR realism and the ease of importing patient-specific data can still be improved, and further studies to quantify and precisely identify benefits are needed.

The impact of surgical simulation on patient outcomes: a systematic review and meta-analysis

The use of simulation in surgical training is ever growing. Evidence suggests such training may have beneficial clinically relevant effects. The objective of this research is to investigate the effects of surgical simulation training on clinically relevant patient outcomes by evaluating randomized controlled trials (RCT). PubMed was searched using PRISMA guidelines: "surgery" [All Fields] AND "simulation" [All Fields] AND "patient outcome" [All Fields]. Of 119 papers identified, 100 were excluded for various reasons. Meta-analyses were conducted using the inverse-variance random-effects method. Nineteen papers were reviewed using the CASP RCT Checklist. Sixteen studies looked at surgical training, two studies assessed patient-specific simulator practice, and one paper focused on warming-up on a simulator before performing surgery. Median study population size was 22 (range 3-73). Most articles reported outcome measures such as post-intervention Global Rating Scale (GRS) score and/or operative time. On average, the intervention group scored 0.42 (95% confidence interval 0.12 to 0.71, P = 0.005) points higher on a standardized GRS scale of 1-10. On average, the intervention group was 44% (1% to 87%, P = 0.04) faster than the control group. Four papers assessed the impact of simulation training on patient outcomes, with only one finding a significant effect. We found a significant effect of simulation training on operative performance as assessed by GRS, albeit a small one, as well as a significant reduction to operative time. However, there is to date scant evidence from RCTs to suggest a significant effect of surgical simulation training on patient outcomes.

Learn EVAR sizing from scratch: The results of a one-day intensive course in EVAR sizing and stent graft selection for vascular trainees

Background and aim

Recognition of structured training in endovascular aortic repair (EVAR) for vascular trainees is increasing. Nevertheless, how trainees can achieve sufficient skills in EVAR sizing and graft selection is sparsely described. The aim of this study was to investigate the effect of systematic training in basic EVAR sizing and graft selection on vascular surgery trainees using a validated assessment tool.

Methods

Sixteen vascular surgery trainees were included in an intensive 6-h hands-on workshop in aortic sizing and stent graft selection for EVAR with a trainer-to-trainee ratio of 1:2. After 1-h lecture, participants did 5 h of supervised training on increasingly complex cases. Finally, the participants were tested using a validated assessment tool.

Results

All participants were able to size the test-case and select a stent graft combination in 24:35 (13:30–48:20) min (median and range). The participants’ overall test scores (lower is better) were in median 17.9 (11.9–28.4). This did not differ from the scores of experienced EVAR operators 14.7 (11.7–25.2) (<200 EVAR’s) ( p = .32) but was inferior to the score of EVAR experts 11.2 (9.8 –18.7) (≥200 EVAR’s) ( p = .01). The sub-score for anatomical measurements was 10.6 (3.9–18.8) and comparable with the experienced group 9.7 (8.1–12.8) ( p = .83) but inferior to the expert operators 6.5 (5.2–10.2) ( p = .04). The sub-score for stent graft selection was 7.5 (4.9–14.1) and comparable with experienced operators scoring 4.5 (3.6–12.3) ( p = .09) but inferior to the expert operators score of 5.0 (3.6–8.4) ( p = .01).

Conclusion

This study presents the results of a standardised one-day basic EVAR sizing and graft selection workshop. Vascular surgery trainees with no prior EVAR experience learned to size and select stent grafts for a simple infra-renal AAA on par with experienced EVAR operators.

Influence of patient-specific rehearsal on operative metrics and technical success for endovascular aneurysm repair

INTRODUCTION

Patient-specific rehearsal (PsR) is a recent technology within virtual reality (VR) simulation that lets the operators train on patient-specific data in a simulated environment prior to the procedure. Endovascular aneurysm repair (EVAR) is a complex procedure where operative metrics and technical success might improve after PsR.

MATERIAL AND METHODS

We compared technical success and operative metrics (endovascular procedure time, contralateral gate cannulation time, fluoroscopy time, total radiation dose, number of angiograms and contrast medium use) between 30 patients, where the operators performed PsR (the PsR group), and 30 patients without PsR (the control group).

RESULTS

The endovascular procedure time was significantly shorter in the PsR group than in the control group (median 44 versus 55 min, p = .017). The other operative metrics were similar. Technical success rates were higher in the PsR group, 96.7% primary and assisted primary outcome versus 90.0% in the control group. The differences were not significant (p = .076).

CONCLUSIONS

PsR before EVAR reduced endovascular procedure time, and our results indicate that it might improve technical success, but further studies are needed to confirm those results.

Patient-Specific Rehearsal Feasibility Before Endovascular Repair of Ruptured Abdominal Aortic Aneurysm

Purpose: To evaluate the feasibility of a patient-specific rehearsal (PsR) before emergency endovascular aneurysm repairs (eEVAR) and its influence on the operation. Materials and Methods: From February 2016 to October 2016, 10 consecutive patients (mean age 75±7.4 years; 9 men) presenting with a ruptured abdominal aortic aneurysm (rAAA) suitable for standard EVAR were enrolled in the study. A 3-dimensional (3D) model of the abdominal aorta was generated on a virtual reality simulator based on the patient’s computed tomography (CT) images. Following the patient-specific simulation setup, PsR was conducted during patient admission or in parallel with the preoperative eEVAR workup. Measured outcomes were PsR feasibility only in the first 4 patients and impact on operative performance thereafter (changes in device selection, the planning process, clinical outcomes, perioperative mortality, and complication rates). Technical metrics and timing of system setup, rehearsal, interval from patient arrival to the actual procedure, and eEVAR were recorded. Results: Mean time for 3D model creation was 21.3±7.8 minutes (range 13–37); there was a significant positive relationship between aortic neck diameter and segmentation time (p=0.003). The overall mean time for simulator setup and PsR was 54±14 minutes (range 37–80); PsR alone was completed in a mean 31±40 minutes (95% confidence interval −60 to −2.2). The actual eEVAR procedure duration was 69±16 minutes (range 45–90). No delay in the actual eEVAR procedure was registered owing to the PsR pathway. In 6 patients, preprocedure rehearsal induced changes in operative strategy, including device selection, main body introduction side, and/or deployment configuration. In 4 cases, rehearsal was performed twice to achieve optimal performance. Conclusion: PsR before eEVAR was feasible in all cases and caused no time delays in the actual eEVAR procedure. PsR optimized eEVAR planning by identifying optimal strategy for stent-graft component selection and deployment.

Team composition and staff roles in a hybrid operating room: A prospective study using video observations

AIM

The aim of the study was to evaluate team composition and staff roles in a hybrid operating room during endovascular aortic repairs.

DESIGN

Quantitative descriptive design.

METHODS

Nine endovascular aortic repairs procedures were video-recorded between December 2014 and September 2015. The data analysis involved examining the work process, number of people in the room and categories of staff and their involvement in the procedure.

RESULTS

The procedures were divided into four phases. The hybrid operating room was most crowded in phase 3 when the skin wound was open. Some staff categories were in the room for the entire procedure even if they were not actively involved. The largest number of people simultaneously in the room was 14.

Simulation training streamlines the real-life performance in endovascular repair of ruptured abdominal aortic aneurysms

OBJECTIVE

Difficulties in distributing endovascular experience among all operating room (OR) personnel prevented full-scale use of endovascular aneurysm repair (EVAR) in emergencies. To streamline the procedure of EVAR for ruptured aneurysm (rEVAR) and to provide this method even to unstable patients, we initiated regular simulation training sessions.

METHODS

This is an observational study of 29 simulation sessions performed between January 2015 and December 2017. We analyzed the development of time from OR door to aortic balloon occlusion during simulations and OR door to needle times in real-life rEVARs as well as the outcome of the 185 ruptured abdominal aortic aneurysm (rAAA) patients who arrived at the university hospital between January 2013 and December 2017. A questionnaire was sent for simulation attendants before and after the simulation session.

RESULTS

In the first simulations, the door to occlusion time was 20 to 35 minutes. After adding a hemodynamic collapse to the simulation protocol, the time decreased to 10 to 13 minutes in the 10 recent simulations, including a 5-minute cardiopulmonary resuscitation (P = .01). The electronic questionnaire performed for attendees before and after the simulation session showed significant improvement in both confidence and knowledge of the OR staff regarding rEVAR procedure. In the real-life rEVARs, 75 of the 185 patients with rAAAs underwent EVAR. Among rEVAR patients, the median OR door to needle time was 65 minutes before and 16 minutes after the onset of simulations (P = .000). The overall 30-day mortality among all rAAA patients was 44.8% and 30.6% accordingly (P = .046). When patients who were turned down from the emergency surgery were excluded, the 30-day operative mortality was 39.2% and 25.1% during the periods, respectively (P = .051). The 30-day mortality was 16.2% after rEVAR and 40.6% after open surgery (P = .001).

CONCLUSIONS

Simulation training for rEVAR significantly improves the treatment process in real-life patients and may enhance the outcome of rAAA patients.