The role of simulation in endovascular surgical training

1. The role of simulation in endovascular surgical training JS Tsang, QMH Joint Hospital Grand Round 26th April 2014

2. Surgical training - concerns • Halsted’s apprenticeship model • Random exposure • Biased assessment • Working time restrictions • Europe – EWTD (58->56->48hrs) • Hong Kong • Patient safety concerns • Trend in restructuring of surgery training

3. Virtual Reality (VR) • Interaction with computer-generated 3D model through an interface device • Well established in aviation • Training in safe environment • Develop Teamwork • Surgical simulation 1993 - Satava Satava RM. Virtual reality surgical simulator. SurgEndosc 1993;7(3):203-5

4. EndoVascular surgery • Minimally invasive surgery • Endovascular surgery • Peripheral vascular disease (PVD) • Carotid stenosis • Aortic aneurysm • Steep learning curve – catastrophic for failure • EVA 3S trial – Carotid stenting 9.6% vs CEA 3.9% (peri-operative stroke rate) • Essential in training curriculum Mas J et al. Endarterectomy versus stenting in patients with symptomatic severe carotid stenosis NEJM 2006; 355:1660

5. Vascular Intervention System Training (VIST)

7. Advantages of simulation training • Realistic • Safe – patient + trainee • Objective assessment • Structured training • Rehearsal • Case • Team rehearsal

8. Carotid artery stenting (CAS) • SAPPHIRE trial1 – CAS not inferior to endarterectomy • Increasing popularity • High-risk procedure – Stroke, death • Use of VR to improve learning curve 1.Yadav JS et al. Protected carotid-artery stenting versus endarterectomy in high risk patients. N Engl J Med 2004;351:1493-501

9. CAS – Study 1 • Dayal et al • Participants: Novice n=16 vs Experienced n= 5 • Pre-training graded procedure • All received 2hrs simulation training • Results: significant improvements in Novice • Procedural time (PT) • Fluoroscopic time (FT) • Catheter and guide wire manipulation • Conclusion: • Improve trainee performance Dayal R et al. Computer simulation as a component of catheter-based training. J VascSurg 2004; 40(6):1112-17.

10. CAS study 2 - Hsu et al • Participants: Untrained n=16 vs experienced n=13 • Initial pre-test • Randomised into simulation training (60mins) vs no training • Final test • Results: • significant improvement in PT after training in both untrained and experienced • Most improvement with Untrained subjects • Conclusion: • Performance correlated with previous experience • Novice may benefit most from VR training Hsu JH et al. Use of computer simulation for determining endovascular skill levels in a carotid stenting model. J VascSurg 40(6):1118-25.

11. CAS study 3 - Patel et al • Participants: 20 experienced cardiologists • All received simulation training • 1.5 days of didactic and simulation training • Results: • Significant improvements in PT, FT, contrast volume and catheter handling time • Conclusion: • Learning curve with improved performance demonstrated on VR simulator Patel AD et al. Learning curves and reliability measures for virtual reality simulation in the performance assessment of carotid angiography. J Am Coll Cardiol 2006; 47(9):1796-802.

12. CAS simulation • Construct validity – • differentiate novice and experienced subjects • Significant improvements in performance • Novice trainees

13. Peripheral angioplasty • Aggarwal et al – • Renal angioplasty and stenting • 20 vascular consultants • 11 inexperienced (<10 cases) • 9 experienced (>50 cases) • All received simulation training • Results: • significant improvements in inexperienced - PT and contrast vol • Similar performance to experienced group after training • Conclusion: • VR simulation helpful in early learning curve Aggarwal R et al. Virtual reality simulation training can improve inexperienced surgeons’ endovascular skills. Eur J Vasc Endovasc Surg 2006;31(6):588-93.

14. Dawson et al • Nine vascular trainees from different states • Iliac stenting • Simulation training x2 days with didactic tutorials • Results: • PT - 54% faster • FT and contrast volume decreased • Time to recognise and manage complications improved • Conclusion: • VR simulation offers realistic practice without risk to patients Dawson DL et al. Training with simulation improves residents’ endovascular procedure skills. J Vasc Surg 2007; 45(1):149-54

15. VR to Operating Room (OR) • Skills transfer to real operating environment Chaer RA et al. Ann Surg 2006; 244:343-52

16. Chaer et al • Participants - 20 residents • Randomised - VR training vs no VR training • All performed 2 graded “real” peripheral angioplasty after 2 hours • Results: • Simulation subjects scored higher – procedural steps and global rating scale • Advantage persisted for second “real” test • Conclusion: • Simulation - valid tool for training residents and fellows • May benefit retraining of vascular surgeons

17. Recent advances:Patient-specific simulation • Mission/ Procedure rehearsal

18. N = 15 • Rehearsal (within 24hrs) then actual CAS • Interventionalist + team members rehearsal • Recorded for analysis • Technical and non -technical skills • Results: • 11/15 patients – identical endovascular tool use • 13/15 patients – identical fluoroscopic angles • 30% patients – simulator did not predict difficult, stenotic artery • Subjective evaluation score 4/5 – realism, technical + communication issues Willaert et al. BJS 2012;99:1304-13

19. N= 9 with abdominal aortic aneurysms • Pre-op rehearsal (within 24hrs) then real EVAR • Results: • PT shorter in simulation vs live EVAR • FT, contrast volume, no. of angiographies – similar • 7/9 patients - C-arm angulation changed significantly after rehearsal • Subjective questionnaire score 4/5: realism, usefulness in rehearsal Desender L et al. EJVEVS 2013;45:639

20. Simulated procedure Real procedure

21. Mission rehearsal Simulated procedure + theatre Real procedure + theatre

22. Angiography simulation suite

23. VR to OR - Laparoscopic surgery • Seymour et al1 – laparoscopic cholecystectomy • Randomised surgical trainees to VR vs standardised training • VR group – fewer intra-op errors • Grantcharov et al2 • VR group – faster, better improvement in error and economy of movements • Seymour et al. Virtual reality training improves operating room performance: results of a randomised , double-blinded study. Ann Surg 2002;236:458-63 • 2. Grantcharov et al. Randomised clinical trial of virtual reality simulation of laparoscopic skills training. Br J Surg 2004;91:146-50

24. VR in Endoscopy • Ahlberg et al • Randomised trainees, surgeons and gastroenterologists • VR training vs control group • Results: VR group better caecal intubation • Shorter time • Less discomfort Ahlberg et al. Virtual reality colonoscopy simulation: a compulsory practice for future colonoscopist? Endoscopy 2005;37:1198-204

25. Conclusion • ‘see one do one’ – no longer feasible • VR simulation – realistic environment • Safe and offers ‘permission to fail’ • Objective assessment and training • Structured and Competency based program • “Mission rehearsal” allows pre-operative planning

26. Conclusion • Studies – small series but encouraging • Improved performance • Construct validity • Shortens learning curve • VR simulation – endovascular surgical training • Adjunct to didactic training + clinical exposure

27. The role of simulation in endovascular surgical training JS Tsang, QMH Joint Hospital Grand Round 26th April 2014