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Virtual Reality Simulation in the Endovascular Field
Table 2: Virtual Reality Endovascular Assessment (Validity) and Training (Learning Curve) Studies
Study Simulator Device Module Face Validity Construct Validity Training Potential Transfer of Training to In Vivo
Wang et al., 2001
24
Accutouch Cardiac lead placement Yes
Dayal et al., 2004
21
VIST Carotid Yes Yes Yes
Hsu et al., 2004
23
VIST Carotid Yes Yes Yes
Nicholson et al., 2006
31
VIST Carotid Yes
Aggarwal et al., 2006
19
VIST Renal Yes Yes
Hislop et al., 2006
22
VIST Carotid Yes
Berry et al., 2006
28
VIST Renal Yes No
Patel et al., 2006
26
VIST Carotid Yes Yes
Chaer et al., 2006
37
VIST Iliac/SFA Yes
Passman et al., 2006
32
SimSuite Iliac/renal/carotid Yes Yes
Dawson et al., 2007
30
SimSuite Iliac Yes Yes
Berry et al., 2007
29
VIST Iliac Yes Yes Yes
Neequaye et al., 2007
36
VIST Iliac/Renal Yes
Van Herzeele et al., 2007
33
VIST Carotid Yes Yes
Van Herzeele et al., 2008
20
Angio Mentor Carotid Yes Yes
VIST = vascular intervention system trainer; SFA = superficial femoral artery.
attributes. Follow-up studies by the EVEREST members will focus on task a training package prior to allowing a physician to perform a CAS procedure
analysis. The aim is to identify the task or step of the CAS procedure on a real patient. Simulation-based training may allow this early part of the
during which most errors are made, and to define and weight those learning curve to take place without exposing patients to unnecessary risks.
different errors. The outcomes of both the task analysis and weighting of However, simulators need to be effective (learning objectives are met) and
the errors should enhance the metrics currently available and may assist efficient (minimization of costs and time taken to achieve proficiency).
35
designers of simulators to implement metrics efficiently.
27
Other simulator Training studies examining the potential use for VR systems in endovascular
companies have incorporated similar assessment parameters to the VIST skills training have analyzed the learning curves of both novice and
(although the definition of the assessment parameters might vary), but experienced subjects. The EVEREST group and others have demonstrated
have also included metrics such as patient selection errors, drug that the performance of experienced endovascular physicians (inexperienced
administration and physiology reporting, overall management, and in CAS) improved during a virtual CAS procedure after a two-day course
complications (e.g. dissections and perforations). The validity of these including supervised training on the Angio Mentor. The intervention post-
assessment methods are under evaluation. course was not only carried out more quickly using less radiation, but, more
importantly, catheter handling errors and spasms of the internal carotid
Although further work is required to validate the different simulators, highly artery occurred less frequently.
23,26,33
Novices improved their simulated
experienced interventionalists in CAS (>50 CAS) agreed that the simulated performance following a minimum of two hours of supervised training on a
CAS procedure (using the VIST simulator) is a realistic interpretation of the carotid VIST module.
21
Similar improvements in simulator performance
actual procedure and provides good force-feedback, and that endovascular following training have been reported for iliac and renal angioplasty.
19,29,30,36
therapists should all train on this model prior to performing CAS in real
patients.
20
Subjective opinions from both inexperienced and experienced The procedure reports provided by the simulators permit supervisors to follow
groups regarding the realism and usefulness of the simulator for training the learning curve of an individual, allowing training to be tailored to a pre-
(Angio Mentor, SimSuite, and VIST) were also positive.
20,23,26,28–33
Basic wire defined benchmark level of skill. However, prior to adoption of VR simulation
and catheter handling skills have previously been acquired by performing into the endovascular curriculum, it is necessary to demonstrate the transfer of
diagnostic catheterization studies. The increased use of non-invasive endovascular skill to real procedures and to show that that these skills are
imaging techniques, budgetary constraints in the interventional room, and maintained over time. Recent evidence of skills transfer using VR simulation
implementation of the European Working Time Directive (EWTD) will restrict suggests that this can be achieved.
29,37
The first randomized trial examining skill
such training opportunities. Additionally, patients have also become more transfer to the human model was carried out by Chaer et al. The simulator-
demanding and less tolerant toward errors, and expect their primary trained group improved significantly during two supervised iliofemoral
operator to be proficient. procedures compared with the control group, using a procedure-specific
checklist and general rating scale to assess performance. The benefit of
The term ‘learning curve’ used in the context of skills training refers to the simulation-based practice is that subjects gain core endovascular skills that
time taken and/or the number of procedures an average practitioner needs become automated by the time that they perform interventions on real patients.
to be able to perform an intervention independently with an acceptable
outcome. Lin et al. have studied sequential groups of patients undergoing The Limitations of Virtual Reality Simulators
CAS and demonstrated that improved outcomes correlated with decreased Currently, simulators are not only expensive, but also their stability remains a
procedure-related complications, fluoroscopic time, and contrast volume problem, in particular following rough handling by inexperienced subjects.
used with increased physician experience.
34
In 2004, the US Food and Drug Keeping the simulators up and running remains a real challenge. There is a
Administration (FDA) reported that simulation might be beneficial as part of noteworthy requirement for regular maintenance and calibration to ensure
US CARDIOLOGY 43
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