Key words
interventional procedures - simulation - education - endovascular training - angiography
Introduction
The travel restrictions during the COVID-19 pandemic pose a serious problem in the
continuous training and recruiting of personnel. A consequence of the ongoing COVID-19
pandemic is the need for social distancing and the adoption of remote communication
paths whenever possible. A recent survey among neurointerventionalists found high
interest on the part of the participants in general online forums, case discussion
forums, and access to video streaming for live mentoring and support [1].
The benefit of simulation training in endovascular medicine has been proven in a number
of recent studies [2]
[3]. Physicians with various levels of expertise benefit from simulation training in
endovascular medicine. Endovascular simulator training improved students’ attitude
towards interventional radiology, increased the likelihood of them choosing interventional
radiology as a subspecialization, and might ease recruitment problems [4]. Simulation training of residents resulted in a shorter total intervention time,
less fluoroscopy time, and less contrast agent usage in neurointerventional procedures
[3]. To attract more radiologists for interventional radiology, it must be recognized
early as a career option [5]. Due to advances in streaming technology, remote proctoring by endovascular specialists
of geographically distant interventionalists is feasible and patient safety can be
increased [6]. Modern simulators allow the transmission of real patient data. Complex elective
examinations can be practiced, and different therapeutic options can be evaluated
in advance with these individualized datasets.
The “Deutsche Gesellschaft für Interventionelle Radiologie und minimalinvasive Therapie”
(DEGIR) is the largest national society of interventional radiologists in Europe.
The organization has been offering simulation-based training sessions as part of radiological
congresses for a number of years to address the outlined issues. Due to the COVID-19
pandemic, these congresses were cancelled with some being replaced by virtual and
online meetings.
To meet the ongoing demand for simulation training in interventional radiology and
to expand the range of endovascular simulation training in the future, the presented
pilot project was developed.
The aim of our study was to test if a curriculum of network-based geographically different
endovascular training sessions led by experts in the field is feasible and to report
initial results from this curriculum.
Materials and Methods
In a pilot phase, participating departments volunteered for the training sessions.
The necessary hardware and a construction manual for the setup of the simulation device
were sent to the participating centers in advance. These six sites were connected
to the internet during the courses. Real-time recordings of the fluoroscopic images,
the user interface of the simulator program, a camera that filmed the hands and materials
of the course participants, and a camera for video telephony could be exchanged among
each other. For this purpose, an online conference program was used (www.goto.com). The most suitable of these options could be selected for the respective course
situation. [Fig. 1] shows an example of a screenshot of a training session.
Fig. 1 Screenshot of a training session. Shown is the demonstration of a percutaneous transluminal
angioplasty of a pelvic stenosis. The instructor's hands are shown on the bottom left,
the selected materials and the virtual patient and C-arm position are shown on the
top left. The generated measurement image for stenosis grading is at the top center,
and the right edge of the screen shows the fluoroscopy image where the roadmap technique
is currently being used to treat the iliac artery stenosis. These images are transmitted
in real time. If necessary, the participants can communicate with each other and with
the instructor via video telephony.
Abb. 1 Screenshot einer Trainingssession. Dargestellt ist die Demonstration einer perkutanen
transluminalen Angioplastie einer Beckenstenose. Unten links sind die Hände des Instruktors
zu sehen, oben links die ausgewählten Materialien und die virtuelle Patienten- und
C-Bogen-Position. Das erzeugte Messbild zur Stenosegraduierung befindet sich oben
in der Mitte und der rechte Bildschirmrand zeigt das Fluoroskopiebild, wo gerade in
Roadmaptechnik die Behandlung der Beckenarterienstenose durchgeführt wird. Diese Bilder
werden in Echtzeit übertragen. Die Teilnehmer können bei Bedarf währenddessen über
Videotelefonie miteinander und mit dem Instruktor kommunizieren.
The expert performed the intervention using a step-by-step approach. It was possible
for the participants to observe the materials and simulator settings selected by the
instructor and to observe the hand movements and fluoroscopic recordings performed
by the instructor in real time. The residents watched the intervention and reproduced
the demonstrated steps.
In turn, the instructor was able to observe the participants' manipulations and fluoroscopic
images. Therefore, the instructor demonstrated part of the intervention, then provided
assistance with any problems the course participants might have had, and then continued
with another part of the intervention until the training goal was achieved. In the
meantime, additional video telephony was used to talk to each other.
Hardware
The endovascular training sessions were performed with the vascular intervention system
trainer VIST B from Mentice (Mentice AB, Gothenburg, Sweden), integrated in the VIST
LAB. The VIST LAB consists of a laptop with a touchscreen function for selecting scenarios
and materials. On this laptop the live stream of the expert and the other participants
can be watched plus one additional monitor where the live image of the intervention
is depicted. A camera is used to depict the manipulation of the material. The simulator
consists of a box with an insertion sheath, which serves as the access point for all
materials. The introduced wires and catheters are detected by sensors, which generate
realistic resistance to the manipulations. The manipulations of the trainee are transferred
into a virtual patient anatomy and displayed on the screens in real time. A footswitch
with two pedals and a control panel for rotating the virtual C-arm as well as the
virtual patient table and other settings are connected to the device. In addition,
a syringe to simulate the injection of contrast medium and a slide switch to simulate
the placement of stents are connected to the simulator. For each simulation, authentic
angiographic materials such as microcatheters and sheaths as well as diagnostic catheters
were used. After the completion of each training, the amount of contrast agent, the
total time, and the fluoroscopy time are depicted and saved. In total, six devices
were used in six participating radiology departments.
Curriculum
Participants were recruited among residents from the participating departments on
a voluntary basis. The simultaneous training of one to three residents with one simulation
device is feasible based on experience from previous simulation courses. In addition
to the course participants, an experienced interventional radiologist was available
at each simulator site. The curriculum consisted of two courses with six lessons that
lasted for one hour with various cases from all fields of endovascular radiology.
In creating the curriculum, care was taken to provide an overview of all endovascular
interventional radiology procedures from head to toe.
At the beginning of each course, the instructor gave a brief introduction to the respective
case and an overview of the disease being treated. However, the main focus of the
course was the manual execution of the intervention.
Then the expert performed the intervention with a step-by-step approach as described
above.
The individual courses build on each other. The courses started with simpler interventions
and more complex procedures were introduced later on. For both series of courses,
an instruction session was given, and the function of the device was explained by
means of a stent implantation in the common iliac artery on the first day of the course.
In the following session, the knowledge of recanalizing measures was expanded by means
of stent implantations in the superficial femoral artery. The following exact course
content varied somewhat in both courses, as can be seen in [Table 1]. Vascular occlusion measures were practiced with separate courses in which a uterine
artery and a gastrointestinal hemorrhage were embolized and transarterial chemoembolization
of the liver was performed.
Table 1
Overview of the completed curriculum of the first and second course and the involved
teaching sites.
Tab. 1 Übersicht über den absolvierten Lehrplan des ersten und zweiten Kurses und die beteiligten
Unterrichtsorte.
|
Course number
|
Teaching site
|
Topic
|
|
1
|
Helios Clinic Krefeld
|
introduction to the device/recanalization of an ipsilateral iliac artery stenosis
|
|
1
|
Saarland University Medical Center
|
recanalization of the superior femoral artery
|
|
1
|
Horst Schmidt Clinic Wiesbaden
|
recanalization below the knee
|
|
1
|
Clemens Hospital Muenster
|
intracranial aneurysm coiling
|
|
1
|
Technical University of Munich
|
transarterial chemoembolization
|
|
1
|
Hannover Medical School
|
renal artery stenosis
|
|
2
|
Helios Clinic Krefeld
|
introduction to the device/recanalization of an ipsilateral iliac artery stenosis
|
|
2
|
Technical University of Munich
|
pelvic and femoral arterial recanalization
|
|
2
|
Saarland University Medical Center
|
emergency interventions
|
|
2
|
Hannover Medical School
|
oncologic interventions
|
|
2
|
Technical University of Munich
|
urogenital interventions
|
|
2
|
Clemens Hospital Muenster
|
acute ischemic stroke
|
Neurovascular cases with the embolization of an aneurysm and thrombectomy of the middle
cerebral artery were presented and practiced.
[Table 1] depicts an overview of the participating sites and the accomplished curriculum in
the first two courses.
Survey design
The participating residents completed questionnaires before and after the course.
Before the survey, the participants were informed that the survey was anonymous and
for research purposes only. All participants gave written informed consent to participate
in the presented study.
The questionnaire consisted of four identical questions before and after the course.
No objectively measurable learning progress was queried during the evaluation of the
course. Participants rated their interest in interventional radiology, the likelihood
of them choosing interventional radiology as a subspecialty, their experience with
endovascular procedures, and their knowledge of endovascular procedures. Six additional
questions after the course recorded the overall satisfaction with the course, the
recommendation rate of the course, the satisfaction with the duration and frequency
of the course, the satisfaction with the teaching content and the pedagogical approach,
and the agreement with the statement that the course should be part of the training
regulations of residency training. A seven-point Likert scale was used in the survey
(1 = “not at all”, 2 = “not”, 3 = “little”, 4 = “neutral”, 5 = “somewhat”, 6 = “a
lot”, 7 = “to the highest degree”).
Data collection
Initially, the responses of 14 participants were recorded using excel spreadsheets.
The rest of the survey was conducted with an online survey tool (Survey monkey, www.surveymonkey.com). The results were analyzed with R 3.6.0 and the figures were created with R as well
(A language and Environment for Statistical Computing, R Foundation for Statistical
Computing, https://www.R-project.org, assessed August 2020) [7]. Statistical significance was tested with the Wilcoxon test for dependent samples.
A p-value less than 0.5 was considered statistically significant.
Results
A total of 43 participants took part in both courses. All participants took the survey
at the beginning of the course. The questionnaire after the courses was completed
by 35 residents (81 %). 43 residents completed the questionnaire before the course.
28 (65 %) of the participants were male and 15 (35 %) were female. The mean age of
the participants was 31 years and the median age was 30 years (IQR 28–32.5).
Compared to the pre-course survey, we found higher approval rates for all post-course
questions.
Respondents’ interest in IR improved from an average of 5.5 (“neutral” to “somewhat”)
to 6.1 (“a lot”). After the course, the percentage of respondents choosing “to the
highest degree” rose from 30.2 % to 40 % and the percentage of negative to neutral
results decreased from 15.3 % to 2.9 %.
Compared to the pre-course survey, the residents’ knowledge about interventional procedures
improved from an average of 4.1 (“neutral”) to 4.6 in the range of “somewhat” to “a
lot”.
We found significant improvement (p = 0.016) in the residents’ self-reported experience
with interventional procedures from an average of 3.7 (“little” to “neutral”) to 4.6
(“neutral” to “somewhat”).
The likelihood of choosing IR as a subspecialty in the future rose from an average
of 5.7 to 5.9 (“somewhat” to “a lot”). The percentage of negative to neutral results
decreased from 18.6 % to 8.6 %.
High approval rates were observed in the additional post-course questions. The average
overall satisfaction with the course was 6.2 (“a lot”) and the median was 6 (IQR 6–7).
No negative or neutral results were measured. The pedagogical approach received an
average approval rate of 6 (“a lot”), the median was 6 (IQR 6–7), and the satisfaction
with the teaching content was 6.4 (“a lot”), the median was 6 (IQR 6–7). The average
satisfaction with the duration and frequency of the course was 6.1 (“a lot”), the
median was 6 (IQR 6–7) and the average approval rate of the statement that the course
should be part of the training regulations in residency training was 5.9 (“a lot”),
the median was 6 (IQR 5–7).
The average level of recommendation to fellow residents was given by the participants
as 6.3, the median was 6 (IQR 6–7). [Table 2] provides an overview of the pre-course and post-course survey and the associated
statistical tests. [Fig. 2], [3] present the results of the pre-course and post-course surveys.
Table 2
Survey comparing pre-course and post-course results. Statistical significance was
tested with the Wilcoxon test for dependent samples. The asterisk indicates a significance
level of a p-value of less than 0.05.
Tab. 2 Umfrage zum Vergleich der Ergebnisse vor und nach dem Kurs. Die statistische Signifikanz
wurde mit dem Wilcoxon-Test für abhängige Stichproben getestet. Das Sternchen kennzeichnet
ein Signifikanzniveau mit einem p-Wert von weniger als 0,05.
|
Item
|
Pre-seminar
|
Post-seminar
|
P-value
|
|
Interest in IR, median (IQR); mean
|
6 (5–7); 5.5
|
6 (6–7); 6.1
|
0.07 503
|
|
Likelihood of becoming an interventional radiologist, median (IQR); mean
|
6 (5–7); 5.7
|
6 (5–7); 5.9
|
0.936
|
|
Experience with endovascular procedures, median (IQR); mean
|
4 (3–5); 3.7
|
5 (3–6); 4.5
|
0.01 606*
|
|
Knowledge about endovascular procedures, median (IQR); mean
|
5 (3–5); 4.1
|
5 (4–6); 4.6
|
0.1404
|
Fig. 2 Depiction of pre- and post-course survey results in a centered stacked bar plot.
The Likert scale defined 7 categories. The percentage of the respective answers is
indicated.
Abb. 2 Darstellung der Umfrageergebnisse vor und nach dem Kurs in einem zentrierten, gestapelten
Balkendiagramm. Die Likert-Skala umfasste 7 Kategorien. Angegeben ist der prozentuale
Anteil der jeweiligen Antworten.
Fig. 3 Depiction of the additional post-course survey results in a centered stacked bar
plot. The Likert scale defined 7 categories. The percentage of the respective answers
is indicated.
Abb. 3 Darstellung der Ergebnisse der zusätzlichen Umfrage nach dem Kurs in einem zentrierten,
gestapelten Balkendiagramm. Die Likert-Skala definierte 7 Kategorien. Angegeben ist
der prozentuale Anteil der jeweiligen Antworten.
Discussion
In the present study we demonstrate that an online, endovascular training curriculum
with simulators in different geographical locations is feasible in real time. The
network incorporated six mobile simulator sites that served as training sites as well
as supervising lecture sites on a rotational basis. We observed a high level of satisfaction
among the participants and a significant gain regarding self-reported experience in
interventional radiology. Our course format appealed to participants with a high level
of preexisting interest in interventional radiology that could even be increased through
the course.
Our results are in good agreement with the results of two previous studies that evaluated
the effect of practical training on students with a dedicated course where a significant
improvement of endovascular skills was noted [8]
[9]. A superior effect of simulator training compared to theoretical seminars was found
in an earlier study with medical students [4].
This significant gain of experience in specific manual intervention techniques of
highly motivated residents might constitute a unique selling point of simulator training.
In times of upcoming intensified recruitment problems, residents need to be trained
more efficiently for a career in interventional radiology to prevent personnel shortages
and a concomitant loss of standing for interventional radiology. Simulator-based training
represents a low-threshold introduction to the world of endovascular radiology. These
training sessions can be used to train residents with an even lower threshold at the
location of their residency.
An often-encountered and weighty argument against using endovascular simulators in
residency training on a routine basis is the high acquisition costs. The purchase
of a simulation device does not pay off for many, especially small and medium-sized,
departments. The presented model with routinely rotating simulation devices which
belong to a professional society could solve this problem. Interested departments
can train their assistants extensively in this way with a device for a few months
before the device is sent on to another hospital. In this way, higher utilization
rates can be achieved than with a stationary device and expert knowledge can be disseminated
more easily without geographic restrictions.
Even after the end of the current travel restrictions, the presented concept represents
a useful supplement to training in the context of radiological congresses to meet
the growing need for standardized and structured training throughout Europe.
Furthermore, the presented network represents a prerequisite for training cases with
real patient data. It seems feasible that a supervised training session run together
with a geographically distant expert in the field can be performed prior to an intervention.
Certification programs of professional endovascular societies (e. g. DEGIR, CIRSE)
face the problem that an essential proportion of endovascular therapy consists of
manual skills. These manual skills cannot be quantified with the established written
and oral exams. The presented study might serve as a blueprint to establish simulation-based
examinations in different geographical locations to quantify these essential therapeutic
skills.
Limitations
Limitations of our study include the relatively small number of participants. As the
presented training curriculum commences, we are confident that larger numbers of participants
will be able to be surveyed in future studies. A further limitation of the study is
the considerable technical effort required. Fast and stable data connections, coordination
efforts, and the availability of functioning simulation devices at the respective
locations are a prerequisite for a functioning training program. Finally, the presented
program is only made possible by the presence and commitment of a sufficient number
of qualified experts in the field.
Conclusion
The realization of a network-based endovascular online training curriculum in different
geographical locations is feasible. The comprehensive curriculum has the potential
to meet the demand for IR training in times of travel restrictions and can complement
future training in the context of radiologic congresses. For interested residents,
the presented online curriculum can offer a low-threshold and comprehensive entry
into the world of interventional radiology at the site of their training.
Clinical Relevance of the Study
-
Simulator-based training in endovascular methods led by experts in the field at different
geographical locations is feasible.
-
A network of simulators allows implementation of a comprehensive endovascular training
program in times of COVID-19-associated travel restrictions.
-
The curriculum has the potential to complement future training in the context of radiologic
congresses.
-
For interested residents, the presented online curriculum can offer a low-threshold
and comprehensive entry into the world of interventional radiology at the site of
their training.
