title: Endovascular aneurysm repair simulation can lead to decreased fluoroscopy time and accurately delineate the proximal seal zone.
abstract: BACKGROUND
  The use of simulators for endovascular aneurysm repair (EVAR) is not widespread. We examined whether simulation could improve procedural variables, including operative time and optimizing proximal seal. For the latter, we compared suprarenal vs infrarenal fixation endografts, right femoral vs left femoral main body access, and increasing angulation of the proximal aortic neck.
  
  
  METHODS
  Computed tomography angiography was obtained from 18 patients who underwent EVAR at a single institution. Patient cases were uploaded to the ANGIO Mentor endovascular simulator (Simbionix, Cleveland, Ohio) allowing for three-dimensional reconstruction and adapted for simulation with suprarenal fixation (Endurant II; Medtronic Inc, Minneapolis, Minn) and infrarenal fixation (C3; W. L. Gore & Associates Inc, Newark, Del) deployment systems. Three EVAR novices and three experienced surgeons performed 18 cases from each side with each device in randomized order (n = 72 simulations/participant). The cases were stratified into three groups according to the degree of infrarenal angulation: 0° to 20°, 21° to 40°, and 41° to 66°. Statistical analysis used paired t-test and one-way analysis of variance.
  
  
  RESULTS
  Mean fluoroscopy time for participants decreased by 48.6% (P < .0001), and total procedure time decreased by 33.8% (P < .0001) when initial cases were compared with final cases. When stent deployment accuracy was evaluated across all cases, seal zone coverage in highly angulated aortic necks was significantly decreased. The infrarenal device resulted in mean aortic neck zone coverage of 91.9%, 89.4%, and 75.4% (P < .0001 by one-way analysis of variance), whereas the suprarenal device yielded 92.9%, 88.7%, and 71.5% (P < .0001) for the 0° to 20°, 21° to 40°, and 41° to 66° cases, respectively. Suprarenal fixation did not increase seal zone coverage. The side of femoral access for the main body did not influence proximal seal zone coverage regardless of infrarenal angulation.
  
  
  CONCLUSIONS
  Simulation of EVAR leads to decreased fluoroscopy times for novice and experienced operators. Side of femoral access did not affect precision of proximal endograft landing. The angulated aortic neck leads to decreased proximal seal zone coverage regardless of infrarenal or suprarenal fixation devices.
authors.affiliation: Division of Vascular Surgery, Harrington Heart & Vascular Institute, University Hospitals Case Medical Center, Cleveland, Ohio.
authors.forename: Ann H
authors.initials: AH
authors.lastname: Kim
authors.affiliation: Division of Vascular Surgery, Harrington Heart & Vascular Institute, University Hospitals Case Medical Center, Cleveland, Ohio.
authors.forename: Daniel E
authors.initials: DE
authors.lastname: Kendrick
authors.affiliation: Department of Physiology and Biophysics, Case Western Reserve University, Cleveland, Ohio.
authors.forename: Pamela A
authors.initials: PA
authors.lastname: Moorehead
authors.affiliation: Department of Physiology and Biophysics, Case Western Reserve University, Cleveland, Ohio.
authors.forename: Anil
authors.initials: A
authors.lastname: Nagavalli
authors.affiliation: Department of Physiology and Biophysics, Case Western Reserve University, Cleveland, Ohio.
authors.forename: Claire P
authors.initials: CP
authors.lastname: Miller
authors.affiliation: Division of Vascular Surgery, Harrington Heart & Vascular Institute, University Hospitals Case Medical Center, Cleveland, Ohio.
authors.forename: Nathaniel T
authors.initials: NT
authors.lastname: Liu
authors.affiliation: Division of Vascular Surgery, Harrington Heart & Vascular Institute, University Hospitals Case Medical Center, Cleveland, Ohio.
authors.forename: John C
authors.initials: JC
authors.lastname: Wang
authors.affiliation: Division of Vascular Surgery, Harrington Heart & Vascular Institute, University Hospitals Case Medical Center, Cleveland, Ohio. Electronic address: vikram.kashyap@uhhospitals.org.
authors.forename: Vikram S
authors.initials: VS
authors.lastname: Kashyap
mesh_terms: D017544:Aortic Aneurysm, Abdominal / Q000000981:diagnostic imaging / Q000601:surgery*; D001027:Aortography / Q000379:methods; D001807:Blood Vessel Prosthesis; D019917:Blood Vessel Prosthesis Implantation / Q000009:adverse effects / Q000193:education* / Q000295:instrumentation; D002983:Clinical Competence; D000072226:Computed Tomography Angiography; D003198:Computer Simulation; D003194:Computer-Assisted Instruction / Q000379:methods*; D004502:Education, Medical, Continuing / Q000379:methods*; D004503:Education, Medical, Graduate / Q000379:methods*; D057510:Endovascular Procedures / Q000009:adverse effects / Q000193:education* / Q000295:instrumentation; D005471:Fluoroscopy; D006801:Humans; D007396:Internship and Residency; D059032:Learning Curve; D009820:Ohio; D011474:Prosthesis Design; D011829:Radiation Dosage; D000069079:Radiation Exposure / Q000009:adverse effects / Q000517:prevention & control*; D015641:Radiography, Interventional / Q000009:adverse effects; D013647:Task Performance and Analysis; D016896:Treatment Outcome