Name: simulator training for endovascular neurosurgery
Uploaded: 2020-05-06T12:30:00
Description: Watch this Scientific Journal Video about Simulator Training for Endovascular Neurosurgery at JoVE.com

The authors thank all the clinical teams contributing daily to the care of neurovascular patients at UCSD.

1. Simulator setup
<ol>
	<li>Prior to all procedures, assemble the simulator as shown in Figure 1 and turn on. Refer to Table 1 for the full list of simulator equipment needed to complete each simulation.</li>
	<li>Select the patient scenario using the software interface on the attached laptop (Figure 1C).</li>
	<li>Select the appropriate arterial sheath or guide catheter&#160;from the drop-down menu. This does not need to be physically insert...

     

<ol>
	<li>See, K. W., Chui, K. H., Chan, W. H., Wong, K. C., Chan, Y. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Evidence+for+Endovascular+Simulation+Training:+A+Systematic+Review.">Evidence for Endovascular Simulation Training: A Systematic Review.</a> European Journal of Vascular and Endovascular Surgery. 51 (3), 441-451 (2016).</li><li>Pannell, J. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Simulator-Based+Angiography+and+Endovascular+Neurosurgery+Curriculum:+A+Longitudinal+Evaluation+of+Performance+Following+Simulator-Based+Angiography+Training.">Simulator-Based Angiography and Endovascular Neurosurgery Curriculum: A Longitudinal Evaluation of Performance Following Simulator-Based Angiography Training.</a> Cureus. 8 (8), 756 (2016).</li><li>Liebig, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Metric-Based+Virtual+Reality+Simulation:+A+Paradigm+Shift+in+Training+for+Mechanical+Thrombectomy+in+Acute+Stroke.">Metric-Based Virtual Reality Simulation: A Paradigm Shift in Training for Mechanical Thrombectomy in Acute Stroke.</a> Stroke. 49 (7), 239-242 (2018).</li><li>Spiotta, A. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Diagnostic+angiography+skill+acquisition+with+a+secondary+curve+catheter:+phase+2+of+a+curriculum-based+endovascular+simulation+program.">Diagnostic angiography skill acquisition with a secondary curve catheter: phase 2 of a curriculum-based endovascular simulation program.</a> Journal of Neurointerventional Surgery. 7 (10), 777-780 (2015).</li><li>Spiotta, A. M., Rasmussen, P. A., Masaryk, T. J., Benzel, E. C., Schlenk, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Simulated+diagnostic+cerebral+angiography+in+neurosurgical+training:+a+pilot+program.">Simulated diagnostic cerebral angiography in neurosurgical training: a pilot program.</a> Journal of Neurointerventional Surgery. 5 (4), 376-381 (2013).</li><li>Fargen, K. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Experience+with+a+simulator-based+angiography+course+for+neurosurgical+residents:+beyond+a+pilot+program.">Experience with a simulator-based angiography course for neurosurgical residents: beyond a pilot program.</a> Neurosurgery. 73, 46-50 (2013).</li><li>Fargen, K. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Simulator+based+angiography+education+in+neurosurgery:+results+of+a+pilot+educational+program.">Simulator based angiography education in neurosurgery: results of a pilot educational program.</a> Journal of Neurointerventional Surgery. 4 (6), 438-441 (2012).</li><li>Cates, C., L&#246;nn, L., Gallagher, A. G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prospective,+randomised+and+blinded+comparison+of+proficiency-based+progression+full-physics+virtual+reality+simulator+training+versus+invasive+vascular+experience+for+learning+carotid+artery+angiography+by+very+experienced+operators.">Prospective, randomised and blinded comparison of proficiency-based progression full-physics virtual reality simulator training versus invasive vascular experience for learning carotid artery angiography by very experienced operators.</a> BMJ Simulation and Technology Enhanced Learning. 2, 1-5 (2016).</li><li>Guo, J., Jin, X., Guo, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Study+of+the+Operational+Safety+of+a+Vascular+Interventional+Surgical+Robotic+System.">Study of the Operational Safety of a Vascular Interventional Surgical Robotic System.</a> Micromachines. 9 (3), 119 (2018).</li><li>Tedesco, M. M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Simulation-based+endovascular+skills+assessment:+the+future+of+credentialing.">Simulation-based endovascular skills assessment: the future of credentialing.</a> Journal of Vascular Surgery. 47 (5), 1008 (2008).</li></ol>

Endovascular surgery is an expanding field that offers a minimally invasive treatment approach to a variety of pathologies. The significant risks associated with vascular injuries nonetheless provides unique educational challenges. With advances in simulation-based training, the education of trainees now allows practice in a risk-free environment that mimics real-life cases. Accordingly, endovascular simulation-based training has been shown to consistently improve performance metrics such as procedure time, fluoroscopy t...

Simulation-based training is an established educational tool for medical trainees and is particularly beneficial in high-risk fields such as endovascular neurosurgery. Multiple virtual reality training devices utilizing catheter-based systems exist, such as the ANGIO Mentor simulator (Simbionix Ltd., Airport City, Israel) and VIST-C and VIST G5 simulators (Mentice AB, Gothenburg, Sweden), with a significant body of data demonstrating the utility of training on procedural aptitude1. In spite of the usefulness of the simulators, step-by-step procedural instructions for their use are lacking.
Presented is a detailed protocol for use of the ANGIO Mentor simulator, a system that supports competency improvements in common endovascular neurosurgery procedures including diagnostic cerebral angiograms,&#160;mechanical thrombectomies, and aneurysm coil embolizations2. Prior work shows that after trainees of all levels performed five simulated angiograms, five thrombectomies, and ten aneurysm coil embolizations on the ANGIO Mentor simulator, they displayed significant improvements in procedural time, fluoroscopy and contrast doses, and adverse technical events2.
The following step-by-step instructions are divided into case scenarios and can easily be integrated into an academic training curriculum for medical students, residents, or fellows2. It should nonetheless be noted that a basic understanding of cerebral arterial anatomy, angiography, and stroke and aneurysm treatments is needed to optimize the educational potential of the simulation device.
All procedures described below (i.e., diagnostic cerebral angiogram, coiling of carotid terminus aneurysm, mechanical thrombectomy) can be performed by a single operator using the ANGIO Mentor simulator (Simbionix Ltd.) (Figure 1). This training device allows neurosurgical trainees of all skill levels to gain exposure to endovascular techniques in a preclinical setting, with the three patient scenarios utilized based on a previously published curriculum for simulator-based angiography training2. To reproduce endovascular techniques with high fidelity, the simulator utilizes actual catheters and wires introduced through a port similar to the diaphragm of a femoral artery sheath. The wires and catheters engage internal rollers that record both rotational and translational motions, which are displayed on the monitors. Device selections and patient vital signs are also visible to the simulator operator.

<table>
	<tbody>
		<tr>
			<td>ANGIO Mentor simulator</td>
			<td>Simbionix Ltd., Airport City, Israel</td>
			<td>N/a</td>
			<td>The setup for the ANGIO Mentor simulator includes the simulator housing as pictured in Figure 1: (A), an external monitor for image projection (x-ray, angiography; B), a laptop for interfacing with the Simbionix Software (C), the simulated femoral artery sheath (with an outer guide-catheter, inner diagnostic microcatheter and guidewire shown; D), a contrast syringe (E), an insufflator for balloon inflation (F), a stent delivery device (G; not used in these patient scenarios), foot pedals for fluoroscopy, roadmap guidance, and angiographic runs (H), and the operator control panel on the simulator housing where the operator is able to control patient and image intensifier positioning (I).</td>
		</tr>
	</tbody>
</table>

simulator training for endovascular neurosurgery

Simulation-based training has become common practice across medical specialties, especially for learning complex skills performed in high-risk environments. In the field of endovascular neurosurgery, the demand for consequence- and risk-free learning environments led to the development of simulation devices valuable for medical trainees. The goal of this protocol is to provide instructive guidelines for the use of an endovascular neurosurgery simulator in an academic setting. The simulator provides trainees with the opportunity to receive realistic feedback on their knowledge of anatomy, as well as haptic feedback indicative of their success in handling the catheter-based systems without negative consequences. The utility of this specific protocol in relation to other neuroendovascular training modalities is also discussed.

The ANGIO Mentor simulator was previously shown to improve the skills of surgical trainees with varying neuroendovascular experience when performing simulated diagnostic angiograms, thrombectomies, and ruptured aneurysm coil embolizations in an academic setting2. In this study, performance metrics for the aforementioned procedures were established over the course of 30 days in one medical student, one neurosurgery resident, two diagnostic neuroradiology fellows, and one endovascular neurosurgery f...

Watch this Scientific Journal Video about Simulator Training for Endovascular Neurosurgery at JoVE.com

Simulator Training for Endovascular Neurosurgery

Simulation of complex, high-risk procedures is critical to the education of medical trainees. A protocol for simulator-based endovascular neurosurgery training in a controlled academic environment is described. The protocol includes stepwise guidelines for trainees of varying levels, with a discussion of the advantages and limitations of this model.

Simulation-based training has become common practice across medical specialties, especially for learning complex skills performed in high-risk ...

Simulation training is increasingly important for learning complex high-risk skills, such as endovascular neurosurgery. This endovascular neurosurgery simulator protocol tests trainees'anatomical knowledge and provides haptic catheter system feedback in a consequence-free environment. Our protocol includes stepwise guidelines for trainees of varying levels, which incorporates didactic instruction as well as a discussion of the advantages and limitations of this model.Demonstrating the procedure will be Robert Rennert, a neurosurgery resident and former endovascular neurosurgery fellow. Before beginning a procedure, assemble and power on the simulator. Select the patient scenario in the software interface on the attached laptop and select the appropriate arterial sheath size from the dropdown menu.Select the appropriate catheter, guidewire, and/or microsystem based on the specific scenario and turn on the A and B plane. Activate the fluoroscopy with the foot pedals and use the joysticks to adjust both the patient and image intensifier positions until the correct posteroanterior and lateral views are obtained. For a four-vessel cerebral angiogram simulation, select a five French femoral sheath, a 0.035 inch guidewire, and a five French diagnostic catheter from the dropdown menu as tools to be used in this simulation.Insert the guidewire into the simulator machine until it registers on the simulation screen signaling that access has been gained. Advance the guidewire until it's visualized in the descending thoracic aorta and continues into the aortic arch. When the guidewire is safely in the aortic arch, hold the guidewire in place and insert a diagnostic catheter over the guidewire through the simulated femoral sheath to the aortic arch.Remove the guidewire and gently depress the contrast syringe plunger to use the fluoroscopy puff technique to simulate contrast injection and briefly opacify the vessels as the catheter is advanced into the desired artery. Next, create a roadmap guide by injecting contrast with the contrast syringe while the roadmap fluoroscopy foot pedal is depressed. Re-insert the wire to selectively catheterize the desired vessel, advancing the catheter over the wire to catheterize the right and left internal and external carotid arteries and left and right vertebral arteries.When each of the vessels is selectively catheterized, use the diagnostic catheter and the simulator contrast syringe to perform angiograms of each of the vessels, obtaining high magnification views of the aneurysm as necessary. Review the angiograms for adequacy before removing the catheter and remove the diagnostic catheter from the simulation sheath. For carotid terminus aneurysm coiling simulation, select a six French guide catheter, a 0.035 inch guidewire, and a four French diagnostic catheter from the dropdown menu.Insert a diagnostic catheter over a guidewire into the aortic arch and insert a guide catheter over the diagnostic catheter through the femoral access site to the aortic arch. Remove the guidewire and create a roadmap guide of the left common carotid artery in the software. Depress the fluoroscopy foot pedal to inject contrast with the contrast syringe and re-insert the guidewire to facilitate selective catheterization of the left common carotid artery and the internal carotid artery.When the guide catheter is within the internal carotid artery, remove the diagnostic catheter and depress the fluoroscopy pedal while injecting contrast to allow the performance of angiographic runs of the left internal carotid cerebral circulation. Measure the aneurysm using the calculation option and select a microcatheter, microwire, and an appropriately sized coil. Insert a microcatheter and microwire through the femoral access site and under roadmap guidance, selectively catheterize the aneurysm with the microsystem.Remove the microwire. Insert the previously selected coil through the femoral access site and slowly advance the coil into the aneurysm. Once the coil is fully inserted, perform a diagnostic cerebral angiogram and assess the patency of the parent artery and aneurysm filling.With patency of the patent artery preserved, detach the coil and remove the coil wire. Place additional coils as needed until complete embolization of the aneurysm or sufficient coverage of the dome is achieved. After a final post-coiling angiography, remove the microcatheter and guide catheter from the simulation sheath site.For a left middle cerebral artery thrombectomy simulation, select a six French guide catheter, a 0.035 inch guidewire, and a five French diagnostic catheter from the dropdown menu. Insert the guide catheter into the left internal carotid artery and perform angiographic runs of the left internal carotid cerebral circulation as demonstrated. Select a microcatheter, a microwire, and a stent retriever device from the dropdown menu.Insert a microcatheter and microwire into the simulated femoral access site and into the left internal carotid artery. And under roadmap guidance, advance the microwire and microcatheter into the left middle cerebral artery carefully past the area of occlusion. Replace the microwire with a stent retriever device and advance the device into the artery distal to the occlusion.Remove the microcatheter, leaving the stent retriever in place at the level of the occlusion. Turn on the simulated aspiration to the guide catheter in the software and pull back on the microwire to retract the stent retriever device into the guide catheter. Remove the stent retriever from the simulated femoral access site and perform an angiogram through the guide catheter to ensure removal of the occlusion.Remove the guide catheter from the simulation sheath site. In a prior study of trainees using this simulator protocol, statistically significant improvements were seen among all the participants in specific performance metrics for all three procedures, including contrast utilization, fluoroscopy time, and total procedural time. In addition, significantly increased Likert scale performance scores were observed, for which a score of one corresponded to failure and a score of five corresponded to excellence based on the procedural technique.In addition to possessing the relevant anatomical knowledge, one of the keys to successful endovascular neurosurgery is a refined tactile sense to avoid vessel wall perforations and dissections. While the simulator includes a haptic feedback system that links complications with poor technique or use of excessive force, modulation of acceptable force during real-world training is critical for safe performance of endovascular techniques.

Research

JoVE Journal

Neuroscience

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