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Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, Leicester, UKDepartment of Cardiovascular Sciences, University of Leicester, Leicester, UK
Leicester Vascular Institute, University Hospitals of Leicester NHS Trust, Leicester, UKDepartment of Cardiovascular Sciences, University of Leicester, Leicester, UK
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.
1. Introduction
In recent years, vascular surgery has seen the introduction of several endovascular techniques. This has resulted in a paradigm shift with increasing evidence supporting the usage of endovascular techniques for the treatment of aneurysmal disease, peripheral arterial disease, and venous pathologies.[
] Endovascular technologies have necessitated a transition in the psychomotor skillset of trainees and established surgeons, as they adapt to entirely new modes of practice. This is further compounded by rapid technological innovations and constant introduction of new devices.[
The aim of specialist vascular surgical training programmes is to produce surgeons capable of independent practice in open and interventional techniques.[
] Internationally, the training and education of vascular surgeons on the constantly evolving and ever growing endovascular techniques is crucial for their continuing professional development. However, within the United Kingdom, vascular trainees within these programmes are recognised to be the most dissatisfied trainees.
] A recent report showed that up to 78% of trainees spent no time in theatre or performing core surgical skills during their most recent workday, and between 78% and 95% spent no time receiving any formal operative teaching.[
Influence of site and operator characteristics on carotid artery stent outcomes: analysis of the CAPTURE 2 (Carotid ACCULINK/ACCUNET Post Approval Trial to Uncover Rare Events) clinical study.
] Similar experiences have been reported in the United States where access to specialised care has languished with opportunities for specialty training in vascular medicine remain limited. In their recent review, Eberhardt et al. highlight that inadequate funding and under-recognition by accreditation and certification bodies are the primary driving forces for limited access to training within vascular medicine.[
] The situation only worsened in light of the COVID-19 pandemic, with significant reduction in operative experience necessitating extension to training for many trainees in order to meet the required level of competence.[
] The requirement to obtain specific operative competencies within a restricted and curtailed training period has left trainees and educators seeking novel and innovative methods to gain competence and confidence within their training programmes.[
High-fidelity simulation is a form of simulation training that provides the learner with an environment which offers a significant degree of realism and believability to the teaching experience through the combined utilisation of: equipment, setting, scenario and personnel.[
The simulated environment acts as a medium for structured mentoring with the added benefit of learning from mistakes, which entirely mitigates against the risk of patient injury and the medicolegal liability.[
]Table I summarises the different types of simulation modalities utilised for acquisition of procedural skills alongside their advantages and disadvantages. Given that most endovascular technologies were adopted in first-line clinical practice only in recent years, there is uncertainty of the value of simulation-based training in gaining endovascular skills.
Table ITypes, advantages, and disadvantages of different technical skill simulators
Simulation Type
Examples
Advantages
Disadvantages
Task Training Simulation
•
Cannulation arm
•
Box trainers
•
Suture mats
•
Injection pads
•
Relatively cheap.
•
Easy to implement.
•
Suitable for low resource settings.
•
Suitable for early stages in clinical practise.
•
Allows for a technical skill to be broken down into the essential component steps or simulating an isolated skill in its own right
•
Low fidelity
•
Does not allow for the replication of the full clinical encounter.
•
Requires additional equipment to create a more realistic experience.
•
Lack of objective feedback from simulator.
Animal/Cadaveric/Wet-Lab Simulation
•
Live or dissected animal tissue material
•
Human tissue/cadavers
•
Provides a high-fidelity experience including anatomical variations.
•
Allows for simulation of an entire procedure.
•
Compatible with imaging (ultrasound/fluoroscopy) during the simulation.
•
Finite limited resource.
•
Costly.
•
Single use.
•
Require specialist facilities with appropriate licensing and ethical consideration.
•
Infection risks.
•
Cannot simulate active bleeding
Virtual and augmented reality
•
Computer based simulation models.
•
Minimally invasive/robotic surgery simulators.
•
High fidelity.
•
Wide range of procedural simulations available.
•
Detailed objective simulator feedback.
•
Easily accessible.
•
Limited support faculty required.
•
Haptic feedback.
•
Re-usable.
•
Wide range of simulation options ranging from specific skill through to full procedures
•
Allows for patient-specific practise by pre-loading with patient’s CT/MRI.
•
Limited use of adjuvant imaging modalities
•
Cost associated with setting up and maintenance.
•
Lack of validated assessment protocols.
Manikins
•
Resuscitation models
•
Trauma models
•
Neonatal/paediatric models
•
Obstetric models
•
Ultrasound trainers
•
Wide range of differing fidelity models available.
•
Ability to replicate physiological response.
•
Programmable.
•
Compatibility with ultrasound imaging.
•
Can be used as part of a hybrid simulation.
•
Detailed performance data collected.
•
Limited suitability for simulating surgical procedures.
•
Not suitable for repeated use in invasive procedures without replacing damaged parts.
This systematic review aims to appraise the currently available evidence regarding endovascular 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.
2. Material and Methods
This review was not suited to one single research paradigm and therefore both constructivism and positivism methodology were employed. Positivism was used to describe and justify the educational interventions and associated assessments to confirm effectiveness and define pedagogy.[
] A constructivist approach was also implemented, through clarification of the underpinning theoretical frameworks that inform education and assessment methodology.[
] By adopting a contextual realism ontological approach, our review allows us to present a description of which endovascular simulation interventions work, and in what specific educational contexts, which is an appropriate approach in a field contaminated by educational and methodological heterogeneity.[
An initial scoping search was conducted to identify and refine the search syntaxes and to establish the relevant inclusion and exclusion criteria. A study protocol was designed which involved a multi-investigator search strategy and document retrieval process. A comprehensive literature review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement using relevant keywords.[
] The specific endovascular techniques and procedures eligible for inclusion were chosen through consensus, and represent the most performed endovascular procedures, in which competency would be expected by the end of vascular surgical training in the UK (Table II). This review embraced all study designs which utilised high-fidelity endovascular immersive extended-reality simulators i.e. virtual reality, augmented reality, and mixed reality as an education intervention with the aim of improving technical skill in relation to pre-specified endovascular procedures. For inclusion, studies needed to describe both baseline and post-intervention performance metrics, to allow for the measurement of change resulting from the educational intervention. Studies embracing medical students, surgical trainees, and consultant surgeons or interventionalists were eligible for inclusion. Research describing outcomes at all levels of Kirkpatrick’s hierarchy were eligible for inclusion.[
Any study design that describes simulation as an education intervention focused on any of the following endovascular techniques / procedures
•
EVAR (Endovascular Aneurysm Repair)
•
TEVAR (Thoracic Endovascular Aortic Repair)
•
BEVAR (Branched Endovascular Aortic Repair)
•
FEVAR (Fenestrated Endovascular Aortic Repair)
•
chEVAR (chimney Endovascular Aortic Repair)
•
EVAS (Endovascular Aneurysm Sealing)
•
chEVAS (chimney Endovascular Aneurysm Sealing)
•
Covered Endovascular Reconstruction of Aortic Bifurcation (CERAB)
•
Peripheral angioplasty
•
Carotid artery stenting
Opinion pieces, editorial letters, commentaries, literature review or systematic review which fails to describe simulation as an education intervention focused on any of the techniques / procedures described previously.
Intervention
Any study which utilises high-fidelity (virtual reality) simulation as the education intervention for the above techniques / procedures.
Any study which fails to use (high-fidelity) simulation as the education intervention for the above techniques / procedures.
Outcome
Any study which describes baseline and end-point measures relating to technical or procedural performance through simulation in relation to the above endovascular techniques / procedures. Studies that describe outcomes at all levels of Kirkpatrick’s adapted hierarchy are eligible.
Any study which fails to describe outcomes relating to technical or procedural performance through simulation in relation to the above endovascular techniques / procedures.
Participants
Any study which includes medical students, junior doctors (or equivalent) and consultants (or equivalent).
Any study which fails to include medical students, junior doctors (or equivalent) and consultants (or equivalent).
Language
Any country, any language, with translation if needed.
With the aid of a clinical librarian, the following online databases were searched from inception date of database up to June 2022 using a standardised search strategy: EMBASE, MEDLINE, Google Scholar, Cochrane, and AMED. Abstracts available from relevant education and vascular surgery societies, including the Association for Medical Education in Europe (AMEE), Association for the Study of Medical Education (ASME), Society for Vascular Surgery (SVS), Association of Surgeons in Training (ASiT) and The Royal College of Surgeons were also searched for the last 6 meetings to ensure any study currently under review, but not fully published, were included. The reference lists of the studies meeting the inclusion criteria were hand-searched for additional relevant studies, as were previous systematic reviews reporting on endovascular simulation, as identified through the scoping searches.
The search syntaxes and an example search strategy are presented in Table III.
Table IIISearch syntaxes and search strategy
Stage
Adjoining word
Search term
Field to search
1
AND
*ENDOVASCULAR ANEURYSM REPAIR/ OR *ENDOVASCULAR ANEURYSM SEALING/ OR ((Angioplasty NOT cardiac) OR "aortic aneurysm" OR "aortic dissection" OR BEVAR OR "Branched Endovascular Aortic Repair" OR "Carotid artery stent*" OR chEVAR OR "chimney Endovascular Aortic Repair" OR chEVAS OR "chimney Endovascular Aneurysm Sealing" OR "Covered Endovascular Reconstruction of Aortic Bifurcation" OR endovascular OR EVAR OR "Endovascular Aneurysm Repair" OR EVAS OR "Endovascular Aneurysm Sealing" OR FEVAR OR "Fenestrated Endovascular Aortic Repair" OR "peripheral angioplasty" OR "Peripheral vascular disease" OR PVD OR TEVAR OR "Thoracic Endovascular Aortic Repair" OR "Varicose veins")
Title
("virtual reality" OR virtual-reality OR VR OR "task trainer*" OR dry-lab OR "dry lab" OR "computer assisted" OR "computer aided" OR simulat*)
Titles of the studies yielded from the search strategy were reviewed by AG and CGC. Of those titles with potential relevance to the research question, the abstracts were independently screened by AG and CGC using an abstract screening tool (Appendix A). Any study passing the abstract screening process proceeded to full-text eligibility assessment, in which AG and CGC independently and blindly validated studies against a full manuscript screening tool (Appendix B). Disputes at the abstract screening stage and full-text eligibility assessment stage were resolved by consensus between AG and CGC.
A data extraction form was developed which included a research quality assessment tool, utilising guidance from Best Evidence Medical Education, PRISMA and Reed et al. (Appendix C and D). [
] The components of the quality assessment were: backgrounds and objectives, research design, education intervention, assessment, results and conclusions, and impact. Each quality item was further classified as assessing research methodology quality or reporting quality. The research methodology quality assessment was completed as a ‘yes/no’ response to six questions focusing on describing the evidence-base, defining the study objectives, executing an appropriate study design, implementation of control groups, evidence of randomisation, and appropriate use of statistical tests. The reporting quality assessment involved twelve items, which included three ‘yes/no’ items reporting on the study design, learner characteristics and matching of outcomes to objectives. Eight reporting quality indicators were scored on a three-point Likert scale, and included: description of the educational intervention, process and outcome of assessment, educational context, and resources utilised; discussion of theoretical models underpinning both the choice of intervention and assessment; details of the application of psychometrics to assessment; and the provision of materials to allow for assessment replication. The educational impact of interventions were classified in accordance with Kirkpatrick’s adapted hierarchy,[
The initial scoping search revealed a significant degree of heterogeneity in methodology and reporting outcomes. The relevant data, results and conclusions were extracted and collated manually from the studies using the electronic data extraction form.
Quantitative analysis was deemed inappropriate due to the risk of serious confounding and bias. Instead, a descriptive synthesis of these studies was performed, summarising key findings and quality components.
3. Results
3.1 Search results
We identified 474 records following initial searching of the databases and alternative sources and following removal of duplicate results. After applying our eligibility criteria, title and abstract screening, and final full-text review, 18 studies met our criteria for inclusion in this review.
The utility of endovascular simulation to improve technical performance and stimulate continued interest of preclinical medical students in vascular surgery.
The PRISMA flow diagram detailing study selection is shown in Figure 1. Agreement between the two reviewers at the full text-eligibility assessment was good (kappa statistic: 0.90). An overview of the included papers is presented in Table II. Data were extracted by AG and CGC, who achieved concordance in 92% of quality ratings.
Figure 1PRISMA Flow Diagram - Summary of the study selection process
Table IV summarises the key information points from the included studies such as: demographics, study design, simulation intervention, assessment tool and results of the eighteen included studies.
Table IVThe role of endovascular simulation in the acquisition of skill. A summary of the included studies
To evaluate the effect of EVAR simulation in boosting the learning curve by quantifying the performance improvement through participation in a series of simulated EVAR procedures.
Participants in the ‘training group’ received three simulation sessions composed of 6 EVAR cases (over a two-week period). All participants completed 2 EVAR cases (1 simple and 1 complex) at the start and end of the study. The simulator used was the endovascular angio mentor dual slim simulator.
Not specified.
The quantitative evaluation was provided by simulator metrics. The qualitative evaluation was an adapted Likert-scale.
Total procedural time Total fluoroscopy time Time for contralateral gate cannulation Contrast medium volume
Significant improvements in total procedure time, fluoroscopy time and total contrast volume use.
n = 12 4 students 4 junior surgery residents (postgraduate year 1 – 3) 4 senior surgery residents (postgraduate year 4 – 7)
To determine how simulating carotid stenting procedures affects objective performance measures in operators of different experience levels
Over a four-week period, participants completed four simulated carotid artery stenting scenarios. The simulator used was Angio Mentor Dual Sim.
Carotid artery stenosis stenting.
The VR simulator calculated metrics regarding performance at the end of each scenario. Qualitative assessments of operator proficiency were performed with a Likert scale, scored by trained investigators.
This allowed for determination of improvement in performance as students progressed through the four scenarios, with the primary outcome measures comparing performance in the first and fourth iteration.
Total procedural time Cumulative fluoroscopy time Contrast agent volume used
Likert-scale (subjective performance assessment)
Significant improvements in total procedure time, fluoroscopy time but no significant difference in total contrast volume use.
n = 6 3 junior surgery residents (no prior independent endovascular experience) 3 experienced EVAR surgeons
To assess the ability of operators to adopt new skills.
Each participant performed variations of 18 simulations, with each case being classified based on the degree of infrarenal angulation (0 – 20°, 21 – 40° and 41 - 66°). In total, each participant performed 72 simulated EVARs (variations of main body access, type of stent graft system). The simulator used was the Angio Mentor Dual Slim.
Endovascular aneurysm repair (EVAR)
The simulation device provided information on clinical metrics following each clinical case. The actual seal zone coverage by the deployed stent graft was calculated mathematically. Comparison in performance between the first and last 10 cases allowed for determination of procedural improvement
Degree of proximal seal covered by the deployed stent graft
Total procedure time Fluoroscopy time
Ordinal ranking system used to grade the deployment trials as acceptable or unacceptable based on the distance of the proximal endograft to the lowest renal artery. (1 = optimal, 4 least optimal)
Significant improvements in total procedure time and fluoroscopy time.
To assess the role of SBT using a high-fidelity VR simulator.
Participants performed an EVAR procedure, followed by four supervised SBT sessions (supervisor was a consultant surgeon or radiologist) over a period of three months, followed by performing the same EVAR procedure that was performed at baseline. The simulator used was the Angiomentor VR Simulator.
Non-ruptured infrarenal EVAR
The simulator automatically records a variety of parameters throughout the procedure. Response to training was quantified through comparison of pre-and-post intervention performance. A modified-Likert scale was used to assess trainee performance (by an independent investigator)
Time Amount of contrast medium used Contact of wires(s) and catheter(s) with vessel wall Presence of endoleak
n = 12 4 students 4 junior surgery residents (postgraduate year 1 – 3) 4 senior surgery residents (postgraduate year 4 – 7)
To quantify trainee improvement through participation in a series of TEVAR-specific simulations.
Participants performed a TEVAR simulation case on four separate occasions with a minimum of five days between the sessions. The simulator used was the Angio Mentor Dual Slim.
Thoracic endovascular aortic repair (TEVAR)
The simulation device provided information on clinical metrics following each session. A Likert-scale qualitative analysis was used to evaluate participant proficiency during each simulation, performed by a qualified thoracic vascular surgeon with thoracic aortic experience. Change in performance between the first and last cases were analysed in conjunction with scoring from a Likert-scale qualitative scale, as adapted from Chaer et al.
Total procedural time Total fluoroscopy time Total contrast volume Likert-scale (subjective performance assessment)
Significant improvements in total procedure time, fluoroscopy time but no significant difference in total contrast volume use.
n = 5 4 vascular surgery fellows 1 radiology resident
Describing the experience in venous endovascular simulation training for performance of diagnostic venography and inferior vena cava (IVC) filter placement.
Each participant performed 20 non-selective cavagrams, 20 selective bilateral renal vein venograms and 20 IVC filter placements. The simulator used was the VIST simulator.
Internal (simulator-based) and external (physician-developed) metrics were measured and obtained. Improvement in performance was determined through comparing metrics between procedure 1 and procedure 20.
Total procedure time Total fluoroscopy time IVC cavagrams Bilateral renal vein venography IVC filter placement Combined errors IVC filter movement Procedural checklist score (max 42) Global rating scale score (max 95)
Significant improvements in total procedure time but no significant difference in fluoroscopy time.
n = 100 50 novice vascular surgery and radiology trainees 50 experienced interventional vascular surgeons and interventional radiologists
To define the use of virtual reality for carotid artery stenosis training in type I and type III aortic arches for novice operators.
Each participants trained on a simulator for two hours whilst receiving feedback about errors and technical skill from experienced tutors. The participants performed a procedure in a right bifurcation carotid stenosis in a type I aortic arch and a right internal carotid stenosis in a type III aortic arch, both before-and-after the learning. The simulator used was the Procedicus VIST system.
Carotid artery stenosis.
Data of performance were collected using a report of some simulator-derived metrics. Improvement in performance was obtained through comparison between pre-and-post intervention scores.
17 metrics including total procedural time, contrast amount, time of scope, time to catheterisation, stent placement accuracy, % of residual stenosis after stenting, % of lesion covered with stent, balloon placement accuracy, % of residual stenosis after ballooning, % of lesions covered with balloon, catheter movements against vessel wall, catheter movements without guidewire, catheter movements near lesion, EPD movements during deployment and EDP movements after deployment
Significant improvements in total procedure time and total contrast volume use.
To evaluate whether training on a simulated device leads to improved performance.
Participants completed three procedures, followed by a two-hour period of structured training on the simulator, followed by 1 hour of operator-led practice on the device. The participants then performed the same three endovascular procedures.
Flush aortography
Selective renal angiography
Angioplasty on ipsilateral iliac artery stenosis
Simulator-generated data allowed for comparison between pre-and-post intervention performance.
Subjective number of errors made and subjective overall performance.
Total procedural time Total fluoroscopy time Total amount of contrast used
Mean number of errors made
Subjective overall performance
Significant improvements in total procedure time, fluoroscopy time but no significant difference in total contrast volume use.
The utility of endovascular simulation to improve technical performance and stimulate continued interest of preclinical medical students in vascular surgery.
n = 41 23 first year medical students 15 second year medical students 3 ‘other’ students
To assess the ability of a simulation-based curriculum to improve the technical performance of pre-clinical medical students.
Each participant performed a renal stent procedure (pre-test). The 8-week curriculum consisted of didactic teaching, lectures, and a weekly 90-minute mentored simulator session (carotid, renal, iliac and superficial femoral artery interventions). Course concluded with a final renal stent procedure on the simulator (post-test). The simulator used was the Simbionix Angiomentor.
Renal artery stenosis stenting
Objective procedural measures were determined and reported by the simulator, and subjective performance was graded by severe expert observers using a structured global assessment scale.
Improvement in technical skill was measured through the comparison of pre-and-post-intervention performance.
Total procedure time Time to the diagnostic angiogram Time to stent deployment Percent residual stenosis Percent of lesion covered by stent Placement accuracy Fluoroscopy time Volume of contrast injected Activated clotting time
Eight-question global assessment score (Likert-scale).
Significant improvements in total procedure time, fluoroscopy time but no significant difference in total contrast volume use.
n = 20 10 third year medical students 10 fourth year medical students
To identify if medical students could acquire the appropriate endovascular skills to perform a renal artery angioplasty and stent procedure on a VR simulator.
Participants treated an identical left-sided nonostial renal artery lesion ten times. An experienced interventionalist rated the performance at the initial and final sessions using generic and procedure-specific rating scales. The simulator used was the VIST.
Non-ostial renal artery lesion
The simulator automatically provides a procedure report for each session. Improvement in performance was ascertained through comparing outcomes in the first iteration to outcomes in the tenth iteration. Additionally, an experienced endovascular interventionalist (external assessment) used two rating scales to assess the candidates.
Procedure time Contrast volume Fluoroscopy time Qualitative metrics
Significant improvements in total procedure time, fluoroscopy time, total contrast volume use and observer scores.
To characterise the progress of trainees using an interventional simulator trainer
Each participant performed five left renal artery angioplasty over the course of six months. The VIST simulator was used.
Left renal artery angioplasty
The simulation device provided information of clinical metrics following each trial. Progression in metrics over the course of the programme was evaluated. Number of mistakes were recorded.
Total procedure time Fluoroscopy times
Number of mistakes.
Significant improvements in total procedure time and fluoroscopy time.
To objectively assess psychomotor skills acquisition of experienced interventionalists attending a two-day CAS course, using a VR simulator.
Two-day course using didactic sessions, case reviews, supervised VR simulation and live-cases.
Carotid artery stenting
The quantitative evaluation was provided by simulator metrics. Clinical errors were also measured by blinded video assessment.
Procedure time Contrast volume Fluoroscopic time Delivery-deployment time Error scores Carotid artery spasm Placement accuracy Residual stenosis Lesion coverage
Significant improvements in total procedure time, fluoroscopy time, delivery-deployment time, spasm of internal carotid artery and median number of errors.
n = 9 Vascular surgery residents (fellow) in the first year of vascular speciality training.
To evaluate trainees’ technical performance before-and-after individualised training with endovascular simulation.
Two-day endovascular skills programme incorporating high-fidelity endovascular procedure simulation, didactic instruction, computer-based training, and tabletop procedure demonstrations. Within the programme, there was eight hours of simulation-based training. The simulator used was SimSuite.
Iliac angioplasty / stenting.
Performance metrics were automatically measured by the simulator.
Change in performance on two index cases performed at the beginning and end of the educational intervention allowed for determination of improvement.
Procedure time Fluoroscopy time Contrast used No of balloon catheters used Number of stents implanted Number of wired used
Significant improvements in total procedure time, fluoroscopy time and total contrast volume use.
n = 20 20 novice surgical trainees 10 randomised to iliac group 10 randomised to renal group
To determine the nature of skills acquisition on the renal and iliac modules of a commercially-available VR simulator.
Participants completed eight sessions on a VR iliac/renal training module and then crossed over to perform two further VR cases of the other procedure.
Iliac stenting / renal stenting
The quantitative evaluation was provided by simulator metrics.
Procedure time Contrast volume Fluoroscopic time Placement accuracy Residual stenosis Lesion coverage Stent:vessel ratio Maximum stent deployment pressure
Significant improvements in total procedure time but no significant difference in fluoroscopy time and total contrast volume use.
n = 20 12 experienced in endovascular procedures (performed > 50 procedures) 8 inexperienced in endovascular procedures (performed < 10 procedures)
To assess the role of a virtual reality simulator for interventional vascular procedures.
Over a two-day period, participants completed six repetitions of the same module (non-ostial left renal artery balloon angioplasty and stent procedure). The simulator used was the VIST simulator.
Non-ostial left renal artery angioplasty and stent procedures.
The VR simulator calculated metrics regarding performance at the end of each repetition.
This allowed for determination of improvement in performance as students progressed through the six repetitions, with the primary outcome measures comparing performance after the second and sixth iteration.
Total procedural time Total amount of contrast used Fluoroscopy time
Significant improvements in total procedure time and total contrast use but no significant difference in fluoroscopy time.
To demonstrate the utility of the VIST simulator as a measuring tool for improvement in performance and a reduction in procedural errors on repeat testing during simulated carotid angiography.
An instructional course on carotid angiography and then performed five serial simulated carotid angiograms on the VIST simulator.
Carotid angiogram
The quantitative evaluation was provided by simulator metrics.
Procedure time Fluoroscopy time Contrast volume Composite catheter handling errors
Significant improvements in total procedure time and fluoroscopy time but no significant difference in total contrast volume use.
n = 29 16 untrained in endovascular procedures (performed or assisted in < 50 procedures) 13 trained in endovascular procedures (performed or assisted in > 50 procedures)
To investigate the utility and validity of a simulator in assessment and teaching of endovascular skills.
Practice consisted of a 30-minute to 60-minute proctored session, formally repeating the 8 steps within carotid artery stenting or experimenting with the simulator. The simulator used was the VIST simulator.
Carotid artery stenosis stenting.
The simulator generated a report for each session, relating to important clinical metrics.
Change in performance was determined through comparing metrics between the pre-test and post-test. Further analysis between the untrained versus advanced group and practice versus no practice group was performed.
Pass (all 8 steps completed within a 60-minute period) or fail
Total time Total contrast material used Total fluoroscopy time Number of tools inserted
Significant improvements in total procedure time but no significant difference in fluoroscopy time and total contrast volume use.
The utility of endovascular simulation to improve technical performance and stimulate continued interest of preclinical medical students in vascular surgery.
The mean number of participants per study was 21 (range: 5 – 100, median: 15, pooled total: 378) in the eighteen included studies. The participants varied broadly in speciality and stage of training. The most frequent participating groups were defined as: vascular surgery trainees / residents (in six (33.3%) studies), radiology trainees / residents (in four (22.2%) studies), general surgery trainees / residents (in four (22.2%) studies), medical students (in four (22.2%) studies), and experienced endovascular surgeons and interventionalists (in seven (38.9%) studies). Fifteen of the included studies were observational studies,
The utility of endovascular simulation to improve technical performance and stimulate continued interest of preclinical medical students in vascular surgery.
The utility of endovascular simulation to improve technical performance and stimulate continued interest of preclinical medical students in vascular surgery.
Many of the studies included were deemed to be of poor to moderate quality. They were found to be lacking in key areas such as: research design (most notably lack of randomisation and use of a control group), description of theoretical principles that underpin the choice of both educational intervention and assessment. The studies were quality assessed using a standardised nineteen-point scale. The scores ranged from 26% to 79% (mean: 61%, mode: 63%, median 63%, s.d. 13%).
While all studies provided a broad and selective description of the literature, none demonstrated a systematic approach in appraising the evidence-base. Thirteen of the 18 provided a clearly defined and well-described objective to the study.
The utility of endovascular simulation to improve technical performance and stimulate continued interest of preclinical medical students in vascular surgery.
In terms of research design, all studies adopted an appropriate study design to answer the given research questions. Six studies explicitly stated the study design within the published manuscript;
The utility of endovascular simulation to improve technical performance and stimulate continued interest of preclinical medical students in vascular surgery.
The utility of endovascular simulation to improve technical performance and stimulate continued interest of preclinical medical students in vascular surgery.
The utility of endovascular simulation to improve technical performance and stimulate continued interest of preclinical medical students in vascular surgery.
Of the 18 studies, six studies provide details relating to the tools and resources required to deliver the educational intervention in enough detail as to facilitate replication.
16 studies fail to describe any theoretical models or conceptual frameworks underpinning the choice of educational intervention, with the remaining two studies providing a limited description.
The utility of endovascular simulation to improve technical performance and stimulate continued interest of preclinical medical students in vascular surgery.
The utility of endovascular simulation to improve technical performance and stimulate continued interest of preclinical medical students in vascular surgery.
The emphasis on simulation within the education interventions varied widely amongst the included studies. The intensity of education varied from an isolated 30–60-minute session to performing 72 simulations over the course of months.
A range of simulators were used, including the Mentice VIST simulator (n = 9) and the Simbionix Angio Mentor simulator (n = 7). In most studies, simulation was the main tool of intervention (n = 16), with only four studies incorporating other educational methods, such as didactic teaching, computer-based training and tabletop procedure demonstrations.
The utility of endovascular simulation to improve technical performance and stimulate continued interest of preclinical medical students in vascular surgery.
The included studies in this review simulated different endovascular procedures as part of the simulation training interventions. The endovascular procedures simulated include: carotid artery stenosis stenting, renal artery angiography and angioplasty, thoracic endovascular aortic repair, IVC filter placement, and infra-renal EVAR. Only four studies directly report utilisation of expert tutor feedback and guidance during the educational components of the programmes (excluding the assessment stages).
The utility of endovascular simulation to improve technical performance and stimulate continued interest of preclinical medical students in vascular surgery.
The utility of endovascular simulation to improve technical performance and stimulate continued interest of preclinical medical students in vascular surgery.
Common outcomes include total procedure time, total volume of contrast used, fluoroscopy time and the number of catheters required. The more advanced simulators reported variables such as percent of residual stenosis, placement accuracy, error frequency and catheter movements. All studies utilised the first or second, and last simulation to evaluate performance. Several studies, in addition to the simulator-reported metrics, used instructor evaluation to monitor participant technical ability improvement.
For example, Dayal et al scored participants out of five for catheter manipulation technique, guidewire manipulation technique, catheter exchange technique and monorail technique.[
The utility of endovascular simulation to improve technical performance and stimulate continued interest of preclinical medical students in vascular surgery.
The utility of endovascular simulation to improve technical performance and stimulate continued interest of preclinical medical students in vascular surgery.
The utility of endovascular simulation to improve technical performance and stimulate continued interest of preclinical medical students in vascular surgery.
The utility of endovascular simulation to improve technical performance and stimulate continued interest of preclinical medical students in vascular surgery.
In all the 18 included studies with the aid of the varying educational interventions, a significant improvement was noted in total procedure time with p-values ranging from 0.001 to 0.05 signifying the degree of significance.
The utility of endovascular simulation to improve technical performance and stimulate continued interest of preclinical medical students in vascular surgery.
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