Vascular access intervention by a nephrologist in Hiroshima.

BACKGROUND: Vascular access intervention (VAI) is a procedure essential to the maintenance of patency in vascular access and has become indispensable to nephrologists. This procedure has changed nephrology to a more exciting field. CONCEPT: This report describes the VAI technique which is based on 15 years of treatment experience of the author of this report and which the author has taught to young nephrologists in Hiroshima.

Real case virtual reality training prior to carotid artery stenting.

BACKGROUND: The majority of procedural training especially in interventional cardiology, still occurs on patients with direct mentoring by experienced physicians during an actual clinical procedure. In recent years there is an increase use of simulators especially for carotid artery stenting. However, most simulators use "generic" predefined cases. METHODS AND RESULT: We report here a simulation done on data of a real patient prior to intervention. The patient's specific carotid anatomy was modeled using CTA on an endovascular simulator. Pre-procedure patient-specific case rehearsal accurately predicted procedure experience. CONCLUSIONS: A case rehearsal prior to an intervention may be useful in the planning and execution of carotid artery stenting. The use of patient specific simulation helps with planning of procedure and device selection, and may lead to use of less contrast and radiation, and shorter procedure duration. These may benefit the patient with increased success and lower complication rates.

Simulation case rehearsals for carotid artery stenting.

A case series of 5 patients is presented assessing the utility of simulation case rehearsals of individual patients for carotid artery stenting on an endovascular simulator. Simulated and operative device dimensions were similar. Results of subjective surveys indicated that face and content validity were excellent. The simulations predicted difficulty with vessel cannulation, however had difficulty predicting post-stent changes in bifurcation angulation. Our experience suggests that it may be feasible to use patient-specific CTA-derived data in the creation of a realistic case rehearsal simulation. The overall utility of this concept, including cost-benefit analysis, has yet to be determined.

Carotid artery stenting: technical issues and role of operators' experience.

Major criticism of randomized clinical trials comparing carotid artery stenting (CAS) and carotid endarterectomy (CEA) focused on the incomplete learning curve of interventionists and the inadequate and outdated technology employed, which might have contributed to the high stroke and death rates in the CAS arm. The effect of the learning curve related to technical expertise and patient selection strongly influences the results of CAS. Due to the devastating potential complications when compared with other endovascular minimally invasive procedures, CAS requires a more strict analysis of operator training and outcome, because improvement in the learning curve is accompanied by a comparative reduction in complication rates. Today, there is a general agreement that requirements for training in CAS are higher than in other fields. In contrast to many endovascular peripheral arterial interventions, CAS represents a more challenging procedure because it involves complex catheter-based skills. Training experience attempts to sensibly reduce strokes that may occur during the unprotected phases of catheterization/approach to the target vessel and the protected phase of ballooning/stenting and cerebral protection device retrieval. Mandatory training, familiarity with the indications and contraindications, and knowledge of the technology and devices are paramount for the success of CAS, and preprocedure, intraprocedure, and postprocedure patient management is essential for reducing morbidity and mortality. These prerequisites are essential to allow CAS to be accepted as a potential alternative to CEA.

How to introduce carotid angioplasty without compromising patient safety.

Carotid angioplasty with stenting (CAS) is increasingly being used in the treatment of extracranial carotid disease and numerous studies have demonstrated its feasibility. However, the exact role of CAS in the treatment of carotid stenosis and its long-term efficacy has not been defined. The assessment of the patient's medical condition, the exact identification of vessel anatomy as well as anomalies of the aortic arch and the cervicocerebral circulation is required for successful and safe performance of CAS. New CAS practitioners would be advised to start their experience in patients with predominantly easier anatomical situation as well as plaque configuration. The appropriate selection of interventional techniques as well as vascular access for CAS is dependent on the anatomy of the aortic arch and of the CCA proximal to the target lesion. Usually a retrograde femoral artery approach to access the CCA is preferred. In order to treat a patient safely with carotid artery stenting, it essential for interventionalists to appropriately chose a patient suited for endovascular therapy, to identify possible sources of complications prior to the interventional procedure as well as to know the key points for a successful carotid artery intervention. An interdisciplinary evidence-based approach will facilitate the choice of optimal intervention for each patient. Finally, trainee programs for physicians starting with CAS as well as facility certification are absolutely mandatory to ensure high success rates as well as low complication rates.

Endovascular training with animals versus virtual reality systems: an economic analysis.

PURPOSE: To assess the relative costs of a virtual reality (VR) laboratory and an animal laboratory for endovascular skills training. MATERIALS AND METHODS: Cost data extracted from a previous experiment was used to perform a financial analysis according to the guidelines published by the National Institutes of Health. The analysis compared the purchase or rental of a Procedicus Vascular Interventional System Trainer to the rental of an animal laboratory. RESULTS: The VR laboratory course cost $3,434 per trainee versus $4,634 in the animal laboratory according to the purchase-versus-rental analysis. The cost ratio was 0.74 in favor of the VR laboratory. Cost ratio sensitivity analysis ranged from 0.25 in favor of the VR laboratory to 2.22 in favor of the animal laboratory. The first-year potential savings were $62,410 assuming exclusive use of the VR laboratory. The 5-year training savings totaled $390,376, excluding the $60,000 residual value of the simulator. Simulator rental reduced the course price to $1,076 per trainee and lowered the cost ratio to 0.23 in favor of the VR laboratory. Findings of sensitivity analysis ranged from 0.08 to 0.70 in favor of the VR laboratory. The first-year and 5-year potential national savings increased to $185,026 and $1,013,238, respectively. CONCLUSIONS: Although evidence remains sparse that the training of interventional skills in artificial environments translates to better performance in human procedures, there are good pedagogic grounds on which to believe that such training will become increasingly important. The present comparison of the direct costs of two such models suggests that VR training is less expensive than live animal training.

Qualification requirements for performing neurointerventional procedures: a Report of the Practice Guidelines Committee of the American Society of Neuroimaging and the Society of Vascular and Interventional Neurology.

The aim of this document is to summarize the existing data derived from regulatory bodies, professional organizations, and clinical trials with direct pertinence to indications and qualifications required for performing neurointerventional procedures and provide recommendations regarding qualifications required for performing individual neurointerventional procedures. Recommendations are provided for performance of cerebral angiography, intra-arterial thrombolysis, carotid angioplasty and stent placement, intracranial angioplasty and stent placement, and endovascular treatment of intracranial aneurysms and arteriovenous malformations.

Starting a carotid artery stenting program is safe.

BACKGROUND: Little is known on the performance of newly initiated carotid artery stenting (CAS) programs. The safety of the procedure is being questioned following the publication of the EVA-3S trial, a study criticized for the limited interventional experience required to enroll patients. METHODS: Within a newly started academic CAS program, patient data and outcomes were collected prospectively. The outcomes of the first 100 consecutive patients treated are reported. A CAS-fellowship-trained interventionalist was involved in all procedures. All patients underwent clinical assessment by a neurologist before and after the procedure, and serial ECG and cardiac enzymes were routinely obtained. Primary outcome measures included 30-day major adverse events (MAE), defined as death, stroke, or myocardial infarction, while on follow-up deaths and ipsilateral strokes were added. RESULTS: Between July 2003 and November 2006, 92 patients had a single internal carotid artery treated, while 7 underwent staged bilateral CAS. In one patient, the procedure was aborted prior to lesion treatment. The 30-day MAE rate per procedure was 1.9% (one major and one minor stroke). By a mean follow-up of 16 months (range 2-42 months), one patient had died of refractory heart failure, while one patient had a minor ipsilateral stroke and three had minor contralateral strokes, corresponding to total MAE per patient of 4%. The rate of any stroke or death was 7%. The rate of restenosis >or=50% per lesion by ultrasound was 3.8%. CONCLUSION: This single center experience suggests that it is safe to start a CAS program following dedicated fellowship.

Experienced endovascular interventionalists objectively improve their skills by attending carotid artery stent training courses.

OBJECTIVE: Carotid artery stenting (CAS) is an advanced endovascular intervention with a steep learning curve. Virtual reality (VR) simulation has been proposed as a means to train and objectively assess technical performance. AIM: To objectively assess psychomotor skills acquisition of experienced interventionalists attending a two-day CAS course, using a VR simulator. METHODS: Both cognitive and technical skills of 11 interventionalists were trained in a two-day course using didactic sessions, case reviews, supervised VR simulation and live-cases. Pre- and post-course skills were assessed through performance on the same CAS procedure using metrics derived from the simulator. RESULTS: Significant differences were noted between pre- and post-course performance for procedure (36 vs. 20min., p=0.005), X-ray (20 vs. 11min., p=0.016) and delivery-retrieval time of the embolic protection device (12 vs. 9min., p=0.007). Advancement of the guiding catheter without a leading wire occurred to a greater extent pre- versus post-course (199 vs. 152mm., p=0.050) as did spasm of the internal carotid artery (4 vs. 2, p=0.049). CONCLUSIONS: This study has objectively proven a benefit for experienced interventionalists to attend CAS courses for skills acquisition measured by a VR simulator. These data can be used to offer participants an insight into their skills and objectively audit course efficacy.

Virtual reality simulation objectively differentiates level of carotid stent experience in experienced interventionalists.

OBJECTIVES: Technical proficiency in carotid artery stent (CAS) procedures is paramount to ensure patient safety. If virtual reality (VR) simulation is to be used as a valid means for credentialing physicians for CAS procedures, the assessment parameters must be able to evaluate the performance during CAS and to differentiate level of CAS experience. The aim of this study was to validate assessment parameters of a commercially available VR simulator (VIST, Vascular Interventional Surgical Trainer, Mentice, Gothenburg, Sweden) during a CAS procedure in experienced interventionalists. METHODS: Forty-five interventionalists (cardiologists, radiologists, vascular surgeons) who had performed at least 100 endovascular therapeutic cases, with varying experience in CAS were recruited: groups A, n = 12 (0 CAS procedures), B, n = 12 (1 to 20 CAS), C, n = 10 (21 to 50 CAS) and D, n = 11 (>50 CAS). All subjects performed a standard CAS procedure with a type I arch and were assessed by quantitative (procedure time, amount of contrast given, number of cineloops recorded, fluoroscopic time) and qualitative (clinical parameters and errors) metrics of the simulator. Participants also rated the realism and training potential of the simulator on a scale from 1 (poor) to 5 (excellent). RESULTS: There were significant differences across the four groups A to D for procedure time (medians 20.5 vs 24 vs 19 vs 16 minutes, P = .002) and fluoroscopic time (12.5 vs 13 vs 10 vs 7 minutes, P < .001), respectively. Total numbers of errors recorded by the VR simulator did not achieve statistical significance (P = .209) across the four groups. All subjects rated the simulator highly (median 4) in terms of realism and training potential. CONCLUSIONS: Total time and fluoroscopic time both recorded by a realistic VR simulator differentiate between levels of CAS experience in experienced interventionalists. Error scoring is currently not a valid mode of assessment and needs refinement.

Endovascular skills training and assessment.

OBJECTIVE: Evolving endovascular therapies have transformed the management of vascular disease. At the same time, the increasing use of non-invasive vascular imaging techniques has reduced the opportunities to gain the required basic wire and catheter handling skills by performing diagnostic catheterizations. This article reviews the evidence for alternative tools currently available for endovascular skills training and assessment. METHODS: A literature search was performed on PubMed using combinations of the following keywords; endovascular, skills, training, simulation, assessment and learning curve. Additional articles were retrieved from the reference lists of identified papers as well as discussion with experts in the arena of medical education. RESULTS: Available alternatives to training on patients include synthetic models, anesthetized animals, human cadavers and virtual reality (VR) simulation. VR simulation is a useful tool enabling objective demonstration of improved skills performance both in simulated performance and in subsequent in-vivo performance. Assessment modalities reviewed include time action analysis, error analysis, global rating scales, procedure specific checklists and VR simulators. Assessment in training has been widely validated using VR simulation. Rating scales and checklists are presently the only assessment modalities that have demonstrated utility outside the training lab. CONCLUSION: The tools required for a structured proficiency based endovascular training curriculum are already available. Organization of training programs needs to evolve to make full use of modern simulation capability for technical and non-technical skills training.

Training for carotid intervention: preparing the next generation.

BACKGROUND: Carotid interventions are performed to reduce the cumulative risk of stroke. The success of the procedure is dependent upon maintaining low operative risk. This article reviews the current state of training for both carotid endarterectomy (CEA) and carotid angioplasty and stenting (CAS). METHODS: Medline searches were performed to identify articles with the combination of the following key words: carotid, endarterectomy, stent, training, assessment and simulation. Manual searches of the reference lists and related papers was conducted. RESULTS: Training and assessment for CEA and CAS follows the traditional apprenticeship model. There is no formal training protocol or objective means of assessment for either carotid endarterectomy or stenting. Models and simulators to allow for training and assessment away from the operative theatre have been developed, and exist for both CEA and CAS. CONCLUSION: The technology exists to allow for both training and assessment of competency to take place in a controlled and objective environment for both CEA and CAS. The use of simulation needs to be robustly evaluated and assessed to both complement and augment existing training programs to ensure that the highest standards of care are maintained for treatment of carotid territory disease. Objective competency based training and assessment is no longer unattainable. Simulators augment this process and without them operative exposure is sporadic and crisis management infrequent.

Synergy and peripheral percutaneous transluminal angioplasty.

Peripheral percutaneous transluminal angioplasty with endovascular stent is a procedure to improve the symptoms of claudication caused by peripheral vascular disease. There is evidence to show that upward of 30% of patients seek further intervention for recurring symptoms in 1 year. This high rate of recidivism necessitates nursing intervention postprocedure in the hospital to promote a lifestyle change. The Synergy Model is useful to develop a relationship between the patient and the nurse that promotes a lifestyle change. The outlined patient who underwent peripheral percutaneous transluminal angioplasty and the nurse characteristics within the Synergy Model lend themselves to frame a short, intense hospital stay inclusive of thorough, patient-centered teaching.

Identification of skills common to renal and iliac endovascular procedures performed on a virtual reality simulator.

INTRODUCTION: There is a learning curve in the acquisition of endovascular skills for the treatment of vascular disease. Integration of Virtual reality (VR) simulator based training into the educational training curriculum offers a potential solution to overcome this learning curve. However evidence-based training curricula that define which tasks, how often and in which order they should be performed have yet to be developed. The aim of this study was to determine the nature of skills acquisition on the renal and iliac modules of a commercially-available VR simulator. METHOD: 20 surgical trainees without endovascular experience were randomised to complete eight sessions on a VR iliac (group A) or renal (group B) training module. To determine skills transferability across the two procedures, all subjects performed two further VR cases of the other procedure. Performance was recorded by the simulator for parameters such as time taken, contrast fluid usage and stent placement accuracy. RESULTS: During training, both groups demonstrated statistically significant VR learning curves: group A for procedure time (p<0.001) and stent placement accuracy (p=0.013) group B for procedure time (p<0.001), fluoroscopy time (p=0.003) and volume of contrast fluid used (p<0.001). At crossover, subjects in group B (renal trained) performed to the same level of skill on the simulated iliac task as group A. However, those in group A (iliac trained) had a significantly higher fluoroscopy time (median 118 vs 72 secs, p=0.020) when performing their first simulated renal task than for group B. CONCLUSION: Novice endovascular surgeons can significantly improve their performance of simulated procedures through repeated practice on VR simulators. Skills transfer between tasks was demonstrated but complex task training, such as selective arterial cannulation in simulators and possibly in the real world appears to involve a separate skill. It is thus suggested that a stepwise and hierarchical training curriculum is developed for acquisition of endovascular skill using VR simulation to supplement training on patients.