Gosling Andre F, Kendrick Daniel E, Kim Ann H, Nagavalli Anil, Kimball Ethan S, Liu Nathaniel T, Kashyap Vikram S, Wang John C
Division of Vascular Surgery and Endovascular Therapy, Harrington Heart & Vascular Institute, University Hospitals Case Medical Center, Cleveland, Ohio.
Department of Physiology and Biophysics, Case Western Reserve University, Cleveland, Ohio.
J Vasc Surg. 2017 Jul;66(1):298-306. doi: 10.1016/j.jvs.2016.11.066. Epub 2017 May 19.
Outcomes from carotid artery stenting (CAS) are related to experience and technical expertise of the operator. Simulation of CAS may enhance clinical proficiency. We interrogated the impact of endovascular simulation of CAS procedures in operators who are at various stages of training.
Twelve trainees (students [n = 4]; junior surgery residents, postgraduate year [PGY] 1-3 [n = 4]; and senior surgery residents or fellows, PGY 4-7 [n = 4]) were apprised of characteristics of an endovascular simulator and CAS procedures. This was followed by four independent sessions that were assessed for objective measures including procedure and fluoroscopy times and contrast agent use. A qualitative analysis grading steps of CAS by two observers using a Likert scale was performed. One-way analysis of variance and paired t-tests were employed for data analysis.
For all participants (n = 12), procedure times (mean, 920 ± 279 seconds for the first session vs 454 ± 156 seconds for the fourth session; P < .01; confidence interval [CI], 315-621) and fluoroscopy cumulative times (mean, 421 ± 230 seconds for the first session vs 222 ± 102 seconds for the fourth session; P < .01; CI, 78-285) decreased with progression of cases. Students and PGY 1-3 residents decreased their procedure times significantly in comparison of initial and final sessions (P < .05 and P < .01, respectively). For all groups, fluoroscopy cumulative times were reduced, and this decrement was significant in the PGY 1-3 cohort (mean, 444 ± 8 seconds for the first session vs 265 ± 51 seconds for the fourth session; P < .01; CI, 81-276). Initial CAS procedure times were significantly different between groups (P < .05), but this was observed to resolve by the final case at study completion. Qualitatively, the Likert scores of students and PGY 1-3 residents significantly improved with case repetition, specifically in the following steps: (1) cannulation of common carotid artery and (2) sizing and deployment of embolic protection device. Senior operators (PGY 4-7) demonstrated consistently better performance overall with minimal change in scoring with case repetition.
Practice leads to improvements in endovascular simulator procedure and fluoroscopy times, especially for more novice trainees. Initial operator performance gaps can be approximated with a few sessions to expected proficiency. Incorporation of endovascular simulators in residency training may assist in shortening the learning curve in rarer endovascular procedures.
颈动脉支架置入术（CAS）的预后与操作者的经验和技术专长相关。CAS模拟可能会提高临床操作熟练度。我们研究了CAS手术的血管内模拟对处于不同培训阶段的操作者的影响。
告知12名受训者（学生[n = 4]；初级外科住院医师，研究生第1 - 3年[PGY 1 - 3][n = 4]；以及高级外科住院医师或研究员，PGY 4 - 7[n = 4]）血管内模拟器和CAS手术的特点。随后进行四个独立的操作环节，并对包括手术时间、透视时间和造影剂使用等客观指标进行评估。由两名观察者使用李克特量表对CAS的步骤进行定性分析评分。采用单因素方差分析和配对t检验进行数据分析。
对于所有参与者（n = 12），随着病例进展，手术时间（第一次操作平均为920 ± 279秒，第四次操作平均为454 ± 156秒；P <.01；置信区间[CI]，315 - 621）和透视累计时间（第一次操作平均为421 ± 230秒，第四次操作平均为222 ± 102秒；P <.01；CI，78 - 285）均减少。与初始和最终操作环节相比，学生和PGY 1 - 3住院医师的手术时间显著减少（分别为P <.05和P <.01）。对于所有组，透视累计时间均减少，且在PGY 1 - 3队列中这种减少具有显著性（第一次操作平均为444 ± 8秒，第四次操作平均为265 ± 51秒；P <.01；CI，81 - 276）。各小组之间初始CAS手术时间存在显著差异（P <.05），但在研究结束时的最后一例操作中这种差异消失。定性分析显示，随着病例重复，学生和PGY 1 - 3住院医师的李克特评分显著提高，特别是在以下步骤：（1）颈总动脉插管和（2）栓塞保护装置的尺寸选择和部署。高级操作者（PGY 4 - 7）总体表现始终较好，随着病例重复评分变化最小。
实践可改善血管内模拟器操作和透视时间，尤其是对于新手受训者。通过几次操作，初始操作者的表现差距可接近预期熟练度。在住院医师培训中引入血管内模拟器可能有助于缩短较罕见血管内手术的学习曲线。
