title: Simulated procedure rehearsal is more effective than a preoperative generic warm-up for endovascular procedures.
abstract: BACKGROUND
  Patient-specific simulated rehearsal (PsR) of a carotid artery stenting procedure (CAS) enables the interventionalist to rehearse the case before performing the procedure on the actual patient by incorporating patient-specific computed tomographic data into the simulation software. This study aimed to evaluate whether PsR of a CAS procedure can enhance the operative performance versus a virtual reality (VR) generic CAS warm-up procedure or no preparation at all.
  
  
  METHODS
  During a 10-session cognitive/technical VR course, medical residents were trained in CAS. Thereafter, in a randomized crossover study, each participant performed a patient-specific CAS case 3 times on the simulator, preceded by 3 different tasks: a PsR, a generic case, or no preparation. Technical performances were assessed using simulator-based metrics and expert-based ratings.
  
  
  RESULTS
  Twenty medical residents (surgery, cardiology, radiology) were recruited. Training plateaus were observed after 10 sessions for all participants. Performances were significantly better after PsR than after a generic warm-up or no warm-up for total procedure time (16.3 ± 0.6 vs 19.7 ± 1.0 vs 20.9 ± 1.1 minutes, P = 0.001) and fluoroscopy time (9.3 ± 0.1 vs 11.2 ± 0.6 vs 11.2 ± 0.5 minutes, P = 0.022) but did not influence contrast volume or number of roadmaps used during the "real" case. PsR significantly improved the quality of performance as measured by the expert-based ratings (scores 28 vs 25 vs 25, P = 0.020).
  
  
  CONCLUSIONS
  Patient-specific simulated rehearsal of a CAS procedure significantly improves operative performance, compared to a generic VR warm-up or no warm-up. This technology requires further investigation with respect to improved outcomes on patients in the clinical setting.
authors.affiliation: Department of Biosurgery and Surgical Technology, St Mary's Hospital, Imperial College, London, United Kingdom. wimwillaert@hotmail.com
authors.forename: Willem I M
authors.initials: WI
authors.lastname: Willaert
authors.forename: Rajesh
authors.initials: R
authors.lastname: Aggarwal
authors.forename: Farhad
authors.initials: F
authors.lastname: Daruwalla
authors.forename: Isabelle
authors.initials: I
authors.lastname: Van Herzeele
authors.forename: Ara W
authors.initials: AW
authors.lastname: Darzi
authors.forename: Frank E
authors.initials: FE
authors.lastname: Vermassen
authors.forename: Nicholas J
authors.initials: NJ
authors.lastname: Cheshire
mesh_terms: D002339:Carotid Arteries / Q000000981:diagnostic imaging / Q000601:surgery*; D002983:Clinical Competence; D003198:Computer Simulation; D018592:Cross-Over Studies; D057510:Endovascular Procedures / Q000193:education* / Q000592:standards; D006801:Humans; D007396:Internship and Residency; D019919:Prosthesis Implantation / Q000592:standards*; D015607:Stents; D013647:Task Performance and Analysis; D014057:Tomography, X-Ray Computed; D014584:User-Computer Interface