see link for dr. lee's presentation at the western vascular
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Stanford Vascular Surgery
Simulation-based Endovascular Skills Assessment: The Future of
Credentialing?
Maureen M. Tedesco, Jimmy J. Pak, E. John Harris, Jr, Thomas M. Krummel,
Ronald L. Dalman, Jason T. Lee
22nd Annual MeetingWestern Vascular Society
September 10, 2007
Vascular Surgery
Disclosures
Jason T. Lee- educational grant from Cordis Endovascular to study simulation technology.
Drs. Dalman, Krummel and Lee: technical grant from Cordis Endovascular in the form of 2 simulators.
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Background
• High-fidelity simulation has become important in surgical education.– Laparoscopy– Endoscopy– Cystoscopy
• Training on simulation improves operating room performance of surgical residents.*
* Seymour et al. Annals of Surgery, 2002
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Background
• Simulation required during physician training for carotid angioplasty and stenting.
• Recent applications:– Skills assessment– Technical competency – Board certification
• American Board of Vascular Medicine• American Board of Surgery
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Purpose
Does global performance
assessment during endovascular simulation correlate well with self-reported procedural skill and prior
experience level?
Vascular Surgery
Vascular Surgery
Methods• 17 general surgery residents interviewing for
vascular fellowship training • Pre-test questionnaire:
– # of major index vascular procedures– # of specific endovascular procedures
• Diagnostic arteriograms• Aortic stent-grafts• Peripheral angioplasty/stenting• Renal stenting• Carotid stenting
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MethodsProcedicus Vascular Intervention System Trainer
(VIST®) simulator: Right Renal angioplasty and stenting (RAS) module
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MethodsSubjects were evaluated by an experiencedinterventionalist using a global rating scale.
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Angiogram
advance wire into suprarenal aorta without forming a J or pushing against obstruction
place pigtail catheter into renal angiogram position/wire manipulation
knowledge of renal anatomy/perform angiogram
Wire Access select proper catheter/wire for renal canalization safely traverse lesion
Intervention
select guiding catheter select appropriate renal stent deploy renal stent select proper balloon for renal angioplasty post-
stent perform completion angiogram
Global Rating Scale (1-5)
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Methods
• VIST® provided objective measurements:– total procedure time– fluoroscopy time– volume of contrast used (mL)– % of lesion covered– placement accuracy– presence of residual stenosis– # of cine loops used
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Methods
• Post test questionnaire:– Grade his/her own performance – Opinion about optimal number of cases
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ResultsLow
Experience (LE,<20)
Moderate Experience
(ME, 20-100)TOTAL
Subjects 8 9 17
Endovascular Cases
(range)
11.1 ± 6.8
(4-20)
46.6 ± 22.6
(25-89)29.9 ± 24.6
(4-89)
Open Cases
(range)
78.8 ± 38.0
(40-150)
75.0 ± 41.1
(40-150)76.9 ± 38.2
(40-150)
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Low Experience
(n = 8)
ModerateExperience
(n = 9)
p value
Globalassessment
2.69 3.55 0.04
Total procedure time (sec)
895.6 947 NS
Fluoroscopy Time 459.6 412 NS
Contrast used (mL)
15.6 19.2 NS
% lesion covered 96.8 94.9 NS
*Placement accuracy (mm)
4.85 6.64 NS
No residualstenosis
(% of group)
75% 89% NS
Number of Cine loops
5.5 4.7 NS
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Low Experience
(n = 8)
ModerateExperience
(n = 9)
p value
Globalassessment
2.69 3.55 0.04
Total procedure time (sec)
895.6 947 NS
Fluoroscopy Time 459.6 412 NS
Contrast used (mL) 15.6 19.2 NS
% lesion covered 96.8 94.9 NS
Placement accuracy (mm) 4.85 6.64 NS
No residualstenosis
(% of group)
75% 89% NS
Number of Cine loops
5.5 4.7 NS
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R 2 = 0.1645
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
0 1 2 3 4 5 6
self assessment score
average global assessment
score
Post-test questionnaire: poor correlation between the global assessment score and
subjects’ self assessment score.
Results
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Results
• Post-test questionnaire:– vascular surgeons = 19.2 ± 14.4 cases– interventional cardiologists = 14.7 ± 14.8
cases– interventional radiologists = 12.3 ± 12.0 cases
• p = NS
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Summary
• Significant difference in a global assessment score between two groups of surgical residents with varying levels of self-reported endovascular experience.
• Global rating scale was able to discern even minimal differences in experience.
• No difference between the two study groups with respect to the VIST objective measurements.
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Limitations
• Only one “expert” observer, no inter-observer variability.
• Each subject underwent only one session, without the opportunity to practice or learn the equipment.
• Stress may have played a role in this testing situation.
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Conclusion
• Correlation between self-reported case completion and global rating score by an observer.
• Objective measures provided by the simulator may not be valid to determine endovascular skills.
• More meaningful criteria to determine how to integrate simulation into skill assessment.
• Future research is required to determine if simulator-based testing should be incorporated into the credentialing of vascular specialists.
Vascular Surgery
Thank you!