title: Patient-specific endovascular simulation influences interventionalists performing carotid artery stenting procedures.
abstract: OBJECTIVE
  The ability to perform patient-specific simulated rehearsal of complex endovascular interventions is a technological advance with potential benefits to patient outcomes. This study aimed to evaluate whether patient-specific rehearsal of a carotid artery stenting (CAS) procedure has an influence on tool selection and the use of fluoroscopy.
  
  
  METHODS
  Following case note and computed tomography (CT) angiographic review of a real patient case, subjects performed the CAS procedure on a virtual reality simulator. Endovascular tool requirements and fluoroscopic angles were evaluated with a pre- and post-case questionnaire. Participants also rated the simulation from 1 (poor) to 5 (excellent).
  
  
  RESULTS
  Thirty-three endovascular physicians with varying degrees of CAS experience were recruited: inexperienced (5-20 CAS procedures) n = 11, moderately (21-50 CAS procedures) n = 7 or highly experienced (>50 CAS procedures) n = 15. For all participants, 96 of a possible 363 changes (26%) were observed from pre- to post-case questionnaires. This was most notable for optimal fluoroscopy C-arm position 15/33 (46%), choice of selective catheter 13/33 (39%), choice of sheath or guiding catheter 11/33 (33%) and balloon dilatation strategy 10/33 (30%). Experience with the CAS procedure did not influence the degree of change significantly (p > 0.05), and all groups exhibited a considerable modification in tool and fluoroscopy preference. The model was considered realistic and useful as a tool to practice a real case (median score 4/5).
  
  
  CONCLUSIONS
  Patient-specific simulated rehearsal of a complex endovascular procedure strongly influences tool selection and fluoroscopy preferences for the real case. Further research has to evaluate how this technology may transfer from in vitro to in vivo and if it can reduce the radiation dose and the number of endovascular tools used and improve outcomes for patients in the clinical setting.
authors.affiliation: Department of Biosurgery and Surgical Technology, St. Mary's Hospital, Imperial College, 10th Floor QEQM Building, South Wharf Road, London W2 1NY, UK. w.willaert@imperial.ac.uk
authors.forename: W I M
authors.initials: WI
authors.lastname: Willaert
authors.forename: R
authors.initials: R
authors.lastname: Aggarwal
authors.forename: I
authors.initials: I
authors.lastname: Van Herzeele
authors.forename: K
authors.initials: K
authors.lastname: O'Donoghue
authors.forename: P A
authors.initials: PA
authors.lastname: Gaines
authors.forename: A W
authors.initials: AW
authors.lastname: Darzi
authors.forename: F E
authors.initials: FE
authors.lastname: Vermassen
authors.forename: N J
authors.initials: NJ
authors.lastname: Cheshire
mesh_terms: D000328:Adult; D000368:Aged; D000800:Angioplasty, Balloon / Q000295:instrumentation*; D016893:Carotid Stenosis / Q000000981:diagnostic imaging / Q000628:therapy*; D057785:Catheters; D002983:Clinical Competence; D003198:Computer Simulation; D004867:Equipment Design; D005471:Fluoroscopy; D006801:Humans; D021621:Imaging, Three-Dimensional; D008297:Male; D008499:Medical Records; D008875:Middle Aged; D008955:Models, Cardiovascular; D011857:Radiographic Image Interpretation, Computer-Assisted; D015641:Radiography, Interventional / Q000295:instrumentation; D012720:Severity of Illness Index; D015607:Stents; D011795:Surveys and Questionnaires; D013647:Task Performance and Analysis; D013813:Therapy, Computer-Assisted; D014057:Tomography, X-Ray Computed; D014584:User-Computer Interface