Training in Carotid Artery Stenting: Do Carotid Simulation Systems Really Help?

Training in Interventional Radiology: A Simulation-Based Approach

Innovations in medical technology have revolutionised both medical and surgical practice. Indeed, with such innovations, training for specific specialties has become more advanced and streamlined. However, despite these novel approaches to train students and specialist trainees, training for interventional radiology (IR) is lagging. While the reason for this lag remains contentious, one of the primary reasons for this issue may be the lack of standardisation for IR training due to a scarcity of specific guidelines for the delivery of IR procedural training. Interventional radiologists manage a vast array of conditions and perform various procedures. However, training for each procedure is largely dependent on the centre and access to a range of cases. Recently, the use of simulation technology has allowed this issue to be addressed. Simulation technology allows trainees to participate in a range of procedures regardless of their centre and availability of cases. Specialties such as cardiology and vascular surgery have already adopted simulation-based technology for trainees and have commented positively on this approach. However, simulation-based training is still lacking in the IR training pathway. Here, we evaluate why IR training can benefit from a more simulation-based approach. We further consider the cost-effectiveness of implementing simulation-based training nationally. Finally, we outline the potential pitfalls that may arise of introducing simulation-based training for IR trainees. We conclude that despite its disadvantages, simulation training will prove to be more cost-efficient and allow standardisation of IR training.

An approach to EVAR simulation using patient specific modeling

BACKGROUND

The Simbionix Angiomentor Procedure Rehearsal Studio (PRS) offers accurate virtual anatomy for measurement, stent graft selection, and deployment of endovascular aneurysm repair (EVAR) devices.

METHODS

Selected Gore Excluder EVAR cases from our EVAR database were reviewed and DICOM data loaded into the Simbionix Angiomentor simulator using PRS software. Using centerline measurements created on PRS, neck diameter (D1), length from lowest renal artery to each iliac bifurcation (Ll and Lr), and common iliac artery diameter (Dl and Dr) were recorded. All measurements for device selection were made based on data recorded on the simulator. Simulated EVAR was then performed using PRS on a dual limb endovascular simulator. Changes in device selection based on intraoperative measurements and use of three-dimensional (3D) anatomic overlay made by the attending vascular surgeon performing the case were recorded. The devices actually used for successful repair were considered gold standard for comparison. At the completion of each virtual case, simulations were rated by an experienced vascular surgeon for realism, imaging quality, and final product on a 5-point scale.

RESULTS

Ten cases with complete operative data and available computed tomography scans were chosen at random. Fifty percent of the cases (5/10) had changes in device length when using the "in vivo" 3D volume filled model and angiographic measurements. Analysis of variance revealed no significant differences between the groups in any measurement-main body diameter P = 0.960; main body length P = 0.643; and contralateral limb length P = 0.333. Review of simulation scoring showed ratings of diminished realism (average 2.3/5) due to unrealistic ease of wire passage and gate cannulation; however, simulation imaging and final product were scored favorably (3.7 and 3.4, respectively).

CONCLUSIONS

The use of centerlines, angiographic measurements, and 3D modeling within the PRS software approaches real-life device selection and represents an opportunity for high fidelity patient-specific preoperative EVAR case rehearsal.

Simulation in cardiothoracic surgical training: where do we stand?

OBJECTIVES

Simulation may reduce the risks associated with the complex operations of cardiothoracic surgery and help create a more efficient, thorough, and uniform curriculum for cardiothoracic surgery fellowship. Here, we review the current status of simulation in cardiothoracic surgical training and provide an overview of all simulation models applicable to cardiothoracic surgery that have been published to date.

METHODS

We completed a comprehensive search of all publications pertaining to simulation of cardiothoracic surgical procedures by using PubMed.

RESULTS

Numerous cardiothoracic surgical simulators at various stages of development, assessment, and commercial manufacturing have been published to date. There is currently a predominance of models simulating coronary artery bypass grafting and bronchoscopy and a relative paucity of simulators of open pulmonary and esophageal procedures. Despite the wide range of simulators available, few models have been formally assessed for validity and educational value.

CONCLUSIONS

Surgical simulation is becoming an increasingly important educational tool in training cardiothoracic surgeons. Our next steps forward will be to develop an objective, standardized way to assess surgical simulation training compared with the current apprenticeship model.

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 < .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 < .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.

Role of simulation in U.S. physician licensure and certification

The evolution of simulation from an educational tool to an emerging evaluative tool has been rapid. Physician certification has a long history and serves an important role in assuring that practicing physicians are competent and capable of providing a high level of safe care to patients. Traditional assessment methods have relied mostly on multiple-choice exams or continuing medical education exercises. These methods may not be adequate to assess all competencies necessary for excellence in medical practice. Simulation enables assessment of physician competencies in real time and represents the next step in physician certification in the modern age of healthcare.

Endovascular image-guided interventions (EIGIs)

Minimally invasive interventions are rapidly replacing invasive surgical procedures for the most prevalent human disease conditions. X-ray image-guided interventions carried out using the insertion and navigation of catheters through the vasculature are increasing in number and sophistication. In this article, we offer our vision for the future of this dynamic field of endovascular image-guided interventions in the form of predictions about (1) improvements in high-resolution detectors for more accurate guidance, (2) the implementation of high-resolution region of interest computed tomography for evaluation and planning, (3) the implementation of dose tracking systems to control patient radiation risk, (4) the development of increasingly sophisticated interventional devices, (5) the use of quantitative treatment planning with patient-specific computer fluid dynamic simulations, and (6) the new expanding role of the medical physicist. We discuss how we envision our predictions will come to fruition and result in the universal goal of improved patient care.