title: Endovascular Simulation Leads to Efficiency and Competence in Thoracic Endovascular Aortic Repair Procedures.
abstract: OBJECTIVE
  Endovascular interventions such as thoracic endovascular aortic repair (TEVAR) have largely replaced invasive open procedures, and have been demonstrated to be effective in treating patients. Our study used endovascular simulation to assess the effect of TEVAR rehearsal on surgical trainees at different levels in training.
  
  
  METHODS
  Participants were oriented on an endovascular simulator and subsequently a simulated TEVAR was performed during 4 separate sessions over a 1-month period. Metrics included total procedure/fluoroscopy time and volume of contrast used. Likert scale qualitative analysis evaluated participant׳s skills involving major procedural steps. Analysis of data across cohorts included 1-way analysis of variance, Kruskal-Wallis, and paired t-tests.
  
  
  METHODS
  All data were collected at University Hospitals-Case Medical Center, Cleveland, OH.
  
  
  METHODS
  In all, 12 trainees in 3 cohorts (student, surgery resident postgraduate year [PGY] 1-3, surgery resident/fellow PGY 4-7, n = 4 each) were recruited.
  
  
  RESULTS
  All trainees reduced total procedure time (mean = 537 ± 148 vs 269 ± 66s, first session vs fourth, P < 0.05, CI: 195-341) and fluoroscopy time (mean = 201 ± 74 vs 110 ± 37s, P < 0.05, CI: 51-132) with TEVAR case progression. The student cohort decreased procedure time from 551 ± 84s to 313 ± 65s (P < 0.05, CI: 189-287) whereas PGYs 1 to 3 decreased procedure time from 591 ± 149s to 264 ± 29s (P < 0.05, CI: 113-541). Use of contrast decreased over time, but the difference was not significant. Participants acquired proficiency after a few runs in most steps of the procedure. The average qualitative score for all groups combined improved significantly (P < 0.03). PGY 4 to 7 trainees had higher technical scores but this was not statistically significant. The initial gap in junior vs senior trainee performance narrowed after a few practice sessions in all aspects evaluated.
  
  
  CONCLUSIONS
  TEVAR rehearsal on an endovascular simulator can reduce overall procedure and fluoroscopy time, independent of trainee skill level or experience, as well as improve subjective measures of technical success. Further studies are needed to compare simulator performance to outcomes in live cases.
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, University Hospitals-Case Medical Center, Cleveland, Ohio. Electronic address: daniel.kendrick@uhhospitals.org.
authors.forename: Daniel E
authors.initials: DE
authors.lastname: Kendrick
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, University Hospitals-Case Medical Center, Cleveland, Ohio.
authors.forename: Andre F
authors.initials: AF
authors.lastname: Gosling
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, University Hospitals-Case Medical Center, Cleveland, Ohio.
authors.forename: Anil
authors.initials: A
authors.lastname: Nagavalli
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, University Hospitals-Case Medical Center, Cleveland, Ohio.
authors.forename: Vikram S
authors.initials: VS
authors.lastname: Kashyap
authors.affiliation: Division of Vascular Surgery and Endovascular Therapy, University Hospitals-Case Medical Center, Cleveland, Ohio.
authors.forename: John C
authors.initials: JC
authors.lastname: Wang
mesh_terms: D017545:Aortic Aneurysm, Thoracic / Q000601:surgery*; D002983:Clinical Competence; D057510:Endovascular Procedures / Q000193:education*; D006801:Humans; D000066908:Simulation Training; D019616:Thoracic Surgical Procedures / Q000193:education*
keywords: Medical Knowledge; Practice-Based Learning and Improvement; aneurysm; assessment; endovascular surgery; simulation; training