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Friday, July 12, 2019

The Role of Simulation in Boosting the Learning Curve in EVAR Procedures 

Clinical Question
Does the use of simulator training for endovascular procedures, specifically EVAR, improve trainees quantitative and qualitative performance?

Take-away Point
Simulation training has the potential to alter the paradigm with which we teach IR trainees from one of apprenticeship to one that is a hybrid of simulator training and mentor training.

Vento V, Cercenelli L, Mascoli C, Gallitto E, Ancetti S, Faggioli G, Freyrie A, Marcelli E, Gargiulo M, Stella A. (2018). The Role of Simulation in Boosting the Learning Curve in EVAR Procedures. J of Surg Edu, 75(2), 534-540. Doi:10.1016/j.jsurg.2017.08.013 

Click here for abstract

Study Design: Cohort Blinded Study

Funding Source: Self-funded

Setting: Vascular Surgery, Department of Experiment Diagnostic and Specialty Medicine, University of Bologna; Bologna, Italy. 

Figure 4. Overall mean qualitative performance: comparison of total performance score (TPS) between the trainee group (blackline) and the control group (gray line) at t0 and t1.


Conventional teaching in medicine is through an apprenticeship model however this is outdated and inadequate for training endovascular specialists of the new generation. Simulator training provides an opportunity to teach trainees prior to performing the procedure on a real patient. This study took 10 vascular surgery residents of varying levels and randomized them into two groups: control and trainee. Each group performed 2 simulated EVAR procedures (basic and complex) at time point 0 and again 2 weeks later. The trainee group additionally performed 6 simulated EVAR procedures over the two weeks, all with the Gore Excluder stent graft. Trainees were evaluated on total procedure time (T­P), total fluoroscopy time (TF), total contralateral gate cannulation time (TG), and contrast medium volume (CM). The qualitative evaluation was based on seven performance criteria including: respect for tissue, handling of endovascular material, knowledge of the tools and procedure, planning, performance, and quality of the final product.

The trainee group significant reduced their TP (48 min ± 12 vs 32 ±8), TF (18 min ± 7 vs 11 ± 6) and CM (121 cc ± 37 vs 85 ± 26); TG was not significantly changed. The control group did not significantly change between the pre- and post-sessions. The trainee group also significantly improved their qualitative score (13.3 ± 5.8 vs 25.4 ± 5.3) while the control group did not. This study demonstrates that both junior and senior residents in endovascular fields can benefit from simulator training for EVAR procedures.


Simulator training has played a role in training throughout many different professions including pilots and astronauts; this method is translatable to interventional radiology as technology improves and the ability to make real-life simulators develops. Many different departments have simulators for vascular access, be it a chicken with an olive under the skin or an actual mannequin. Advances in technology have now allowed us to create more complex simulators including ones in which real patient information can be input. The use of the simulators has the potential to significantly alter the way IR residents are trained, shifting from an apprenticeship method to one that includes both simulator training and mentor training. Not only is this applicable to EVAR but it can be extrapolated to include ablations, TIPS, vessel selection, aneurysm coiling; the possibilities are endless. Simulator training also affords a better experience for trainee, attending and patient alike if the trainee has improved confidence and skill when performing the procedure. We must, however, also demonstrate that the skills learned in the sim lab translate to those performed in the IR suite.

Post Author:
Nicole A. Keefe, MD
Fellow Physician
Department of Radiology and Medical Imaging
University of Virginia

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