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1 Evolution ofIR Training
5
Lastly, this pathway provides a training option in IR for those
who develop and interest after starting DR.
The certication process is the same regardless of the
residency, in that IR residents in both the integrated and
independent programs take the same DR core examination as
the DR residents. Subsequently, certication in IR/DR
requires passing a combined computerized and oral examination after completion of training. The oral examination is
considered an essential tool for assessing competency in IR,
and was therefore retained for this certicate, although it has
been dropped for DR.
The IR/DR certicate is unusual in that it indicates competency in two ABR primary specialties, IR and DR.This is
a foundational concept, in that the IR/DR certicate can be
used as the parent specialty certicate for other DR subspecialties, such as pediatric radiology or neuroradiology. More
important, it emphasizes that general imaging competency is
unique to IR compared to all other specialties that perform
image-guided interventions. This competency is the special
feature that IR brings to medicine and which all of the ABMS
member boards wanted preserved in the IR specialty
certicate.
IR training has been evolving for the entire history of the
specialty and will continue to evolve. With each change new
opportunities arise, as well as challenges. Initial accreditation of fellowships unied training programs and made
system- wide changes feasible. Recognition as a specialty
was based on the importance of non-procedural patient care
and maintaining imaging competency. The next steps may be
development of areas of content expertise to a level that
would benet from training beyond residency. Perhaps
oncology or vascular fellowships would produce individuals
with special competency in these areas. However, the very
same issues that arose when the idea of recognized VIR fellowships was debated in the 1980s are likely to surface again;
concerns about disenfranchising IRs who do not seek additional training or weakening of the structure of IR by allowing subgroups to differentiate. As in the past, IR will nd a
way, and this exciting specialty will continue to innovate,
advance care, and lead in image-guided interventions.
References
1. Seldinger SI.Catheter replacement of the needle in percutaneous
arteriography; a new technique. Acta Radiol. 1953;39:368–76.
2. Grigg ERN. The RSNA historic symposium on American
Radiology: then and now. Radiology. 1971;100:1–26.
3. Berberich J, Hirsch S. Die Rontgenographische Darstellung der
Arterien und Venen im lebenden Menschen. Klin Wchnschr.
1923;49:2226.
4. Baum S, Athanasoulis C. The beginnings of the Society of
Interventional Radiology (SIR, née SCVIR, SCVR). JVasc Interv
Radiol. 2003;14:837–40.
5. Ferris EJ, Baron MG, Becker GJ, Gardiner GA Jr, Levin
D.Cardiovascular and interventional radiology fellowship training
programs. Radiology. 1989;170:959–60.
6. Kaufman JA. The interventional radiology/diagnostic radiology certicate and interventional radiology residency. Radiology.
2014;273:318–21.
Simulation Training inInterventional
Radiology
GabrielBartal andJohnH.Rundback
Introduction
Medical simulation is a cross-disciplinary realistic and economical training and feedback method, in which learners can
repeatedly practice and review tasks and processes using
physical or virtual reality models. Simulation allows trainees
to learn, develop, maintain, and improve skills in virtual
environments or on models. They can be used until required
prociency is achieved, without harming the patients.
Moreover, simulation-based education facilitates knowledge, ability, and approach that can be safely and efciently
acquired by student and/or physician. Simulated procedurebased skills and team working can be learnt, rehearsed, and
measured, thus providing a base for certication in specic
elds of medical practice.
Medicine has traditionally relied on a “see one, do one”
approach to learning and experience. This exposes patients
to inexperienced health-care practitioners, and the dangers
and harm associated with this are increasingly unacceptable
[1]. It is essential to explore, dene, and implement models
of physicians training models that do not expose the patient
to preventable errors [2]. One such model is simulationbased training [1, 2].
Simulation is a model of an object, process, or system that
can be manipulated in some way. It replicates some aspects
of reality known as the “simuland” (i.e., the object, process,
or system that is simulated). The value of simulation is a
function of its ability to stand for the “simuland” with sufcient delity (accuracy) to serve trainee’s purpose.
With recent advances in medical imaging technologies like CT angiography and MR angiography, most of
G. Bartal (*)
Diagnostic and Interventional Radiology, Meir Medical Center,
Kfar Saba, Sackler Medical School, Tel Aviv University,
Tel Aviv, Israel
J. H. Rundback
Holy Name Medical Center, Interventional Institute,
Teaneck, NJ, USA
e-mail: jrundback@airsllp.com
2
the diagnostic angiographic procedures (i.e., peripheral
angiography, angiography in a bleeding patient, and
almost any kind of diagnostic angiography) have become
less common, reducing the number of occasions to learn
basic catheter manipulation skills [2]. Nevertheless,
gaining selective catheterization skills is necessary for
therapeutic endovascular interventions.
The RSNA (Radiological Society of North America),
SIR (Society of Interventional Radiology) and CIRSE
(Cardiovascular Interventional Radiology Society of
Europe) established a joint medical simulation task force in
order to improve patient care by guiding the implementation
of simulation in IR [3]. The United States Food and Drug
Administration (FDA) also promotes adoption and implementation of simulation training in IR.For example, FDA
requires mandatory prociency training in a simulator
before prior to performing carotid artery stenting (CAS) on
patients [4].
Medical Error
Medical error is one of the most challenging problems of
modern medicine. It is also one of the drivers to develop reliable and cost-effective best tools for simulation. Here are
some examples of the scope of the problem:
• 1997: 180,000 deaths annually from medication errors
and adverse reactions [5].
• 1999: 44,000 to 98,000 deaths annually from medical
errors [6].
• 2000: 225,000 deaths annually from medical errors,
including 106,000 deaths due to “non-error adverse
events of medications” [7].
• 2010: The Ofce of Inspector General for Health and
Human Services said that bad hospital care contributed to
the deaths of 180,000 patients in Medicare alone in a
given year.
• 2013: Serious harm seems to be 10- to 20-fold more com-
mon than lethal harm.
© Springer International Publishing AG, part of Springer Nature 2018
N. A. Keefe et al. (eds.), IR Playbook, https://doi.org/10.1007/978-3-319-71300-7_2
7
8
G. Bartal and J. H. Rundback
• According to the Journal of Patient Safety, the numbers
may be between 210,000 and 440,000 patients. These
numbers make medical errors the third medical cause of
death.
These sobering facts emphasize the need for methodical
and standardized practitioner training to reduce error.
History ofMedical Simulation
Medical simulation has a very long history; the rst evidence
comes from ancient Egypt, around 2000BC, where surgeon
priests simulated surgical procedures (e.g., rhinoplasty) on
cadavers. Parisian Dr. Gregoire in the seventeenth century
created a manikin from cadaver pelvis with skin stretched
across it to simulate an abdomen and with the help of a dead
fetus explained assisted complicated deliveries. In 1739 Dr.
William Smellie introduced a mechanical labor device by
creating female models from a real pelvis, with ligaments,
muscles, skin, articial materials, and cloth dolls to simulate
the fetus. By 1747, he had three machines, with six “articial
children.”
In the modern era, simulation in medical education started
with the use of standardized patients. For interventional radiologists, the case conference has been a long-standing form
of simulation. Today, simulation training using devices and
technology is becoming more common. Initially, simulation
training used computer-based training modules such as
RSNA’s Medical Imaging Resource Center and the
AuntMinnie.com Case of the Day [2].
Professions that require precise cognitive and physical
tasks in high-risk environments are the best candidates for
simulation training. Medical simulation is often used as a
tool to assist a fellow or resident to practice performing a
given procedure to improve prociency. It can be practiced
either under the guidance of a mentor, with performance
feedback being provided by the mentor, or in a self-directed
mode, with self-assessment coming from the learner.
Recently, with implementation of computer-based training,
the performance data is provided by the simulator.
Traditional Training
Training based on the current “see one, do one, teach one”
model is insufcient as trainees learn by practicing on real
patients, which can be an issue when performing interventional procedures. Modern hands-on medical and procedural
training is limited by duty hour restrictions, intolerance for
the use of live animal, medicolegal concerns, and the
increasing range and complexity of procedures and instru-
ments that must be mastered. Indeed, residents have
expressed feeling inadequately trained to perform unsupervised procedures safely exposing patients to unnecessary
harm [7]. Equally, mature practitioners have an ongoing
need for maintaining familiarity with infrequently used
devices or new devices and procedures.
Two categories of skills that may benet from simulation training: procedural and non-procedural. Procedural
ones include the physical skills a physician requires to
complete an interventional procedure. Non-procedural
skills encompass interpersonal, cognitive, or interpretive
competencies.
Types ofSimulators
1. Phantoms or Part Task Trainers: Models of Anatomical
Regions Aimed to Teach Specic Skills
Low-tech task trainers remain at the heart of clinical skills
and procedural instruction. They are fundamental in the
teaching of anatomic landmarks and in enabling learners to
acquire, develop, and maintain the necessary motor skills
required to perform specic tasks.
For example, realistic 3D patient-specic renal biopsy
phantoms have been created using CT data, manufactured
from an organ mold and casted thereafter (Fig.2.1). Using
gelatin gel materials with calibrated parameters allows phantoms to provide realistic mechanical, ultrasound, and CT
properties and mimics various pathologies (Fig.2.2) [8].
For biopsies, practice is important for maintaining and
improving skills [6], yielding faster performance, reducing
the number of missed target lesions [1], lowering procedure
room time [7], and improving success rates [8]. Even experienced radiologists face a learning curve when equipment
changes are made [7]. Thus, realistic phantoms can be useful
for both practicing radiologists and trainees.
2. Computer-based learning modules are digital simulations
on the computer.
3. Computer-assisted mannequins are full body models that
can simulate physiological responses.
4. Virtual reality simulators are immersive environments
simulating live experience for the user and resembling the
“real world.” For instance, Mentice AB (Gothenburg,
Sweden) has created virtual reality simulation platforms
for both uterine artery and prostatic artery embolization.
5. Augmented reality simulators use the existing environ-
ment, overlay digital information on top of it, and then
integrate digital simulation with physical simulator’s
environment in real time.
2 Simulation Training inInterventional Radiology
9
Fig. 2.1 Kidney box phantom CT scan (upper row) and US images
(lower row) [8]. (a, c) Phantom and ultrasound demonstrating a focal
lesion (red arrow) within the lower pole of the right kidney. (b, d) The
kidney is visualized in relation to the liver for ablation planning. (e) The
Fig. 2.2 Schematic
presentation of the kidney
phantom [8] (Reprinted by
permission from SafeToAct
Ltd. © 2017)
10L ablation probe is visualized adjacent to and then within the renal
lesion. The phantom box can aid in procedural planning in order to
avoid vital structures and practice technique (Reprinted by permission
from SafeToAct Ltd. © 2017)
10
G. Bartal and J. H. Rundback
The educational validity of simulators is evaluated based
on ve aspects [9–11]:
1. Face validity evaluates how well a simulator mirrors real
life. This is easiest to assess and is done by surveying
participants regarding the realism of the simulator.
2. Content validity measures of how well a simulator tests
knowledge; it is intended to show how well the simulator
trains one in the expected skills. This can be assessed by
pre- and post-knowledge test to determine improvements
in test score.
3. Construct validity determines how well a simulator can
differentiate participants by skill level. This can be
assessed by including trainees of different experience
levels in order to determine whether the nal scores
differ.
4. Concurrent validity compares simulators with standard
methods. This compares the simulation and the apprenticeship or didactic model.
5. Predictive validity evaluates how well performance on a
simulator predicts performance in real case. This is the
hardest validity to determine.
Animal Simulation Labs
The use of animals for research and clinical training is both
expensive and limited for one-time training events. Supply,
ethical, and legal limitations support the use of non-animal
alternatives (i.e., simulators). Several professional societies
no longer allow the use of live animals in clinical training
programs but endorse simulators instead [13].
Virtual Reality Simulation
This is a sophisticated and complex algorithm-based digital
visualization of a medical procedure manipulated by a hardware component that an operator can interactively use in real
time to accurately practice and test a surgical procedure [14,
15]. It contains all the benets of a box/endo trainer, pro-
vides an added value of practicing full procedures, and
allows learning the anatomy from different perspectives and
practicing and managing complications. It can also provide
accurate feedback on performance.
Catheterization andAngiography
Challenges inInterventional Radiologist’s
Training
Training in IR is inherently visual and requires “hands-on”
experience. Residents or fellows are usually trained 1:1 or
2:1 with a scrubbed supervisor. A senior operator’s view is
an ideal additional teaching tool as he or she can comment in
real time and impart specic valuable knowledge. Senior
trainees do require supervision but also require a degree of
independence to make decisions. This balance is hard to
achieve as patient safety is overriding.
One of the limiting factors for many young IR physicians
is a fear of personal radiation exposure (refer to Chap. 3 for
more information on radiation safety). One of the important
sources of personnel exposure is uoroscopy time. Medical
simulation allows practitioners to improve their performance
in radiation-free conditions. Better and efcient performance
of procedures will reduce uoroscopy time and radiation
exposure.
One of the most important guidance tools in image-guided
interventions is ultrasound; this requires skill in scanning,
image interpretation, and needle guidance [1]. Ultrasoundguided procedure simulations have shown improvement in
knowledge maintenance, skills, and self-condence, compared to pre-simulation training achievements [12].
Currently, most simulation is directed toward the vascular
eld, which is more complex and requires a very skilled
operator.
Catheterization and angiography are basic and important
skills that one must master in order to become a competent
interventional radiologist. Different techniques including
uoroscopy, road mapping and DSA (Digital Subtraction
Angiography) can be practiced on simulators. Simulation
can both shorten the training time and improve catheter skills
[16]. It has been shown to effectively train catheter-based
endovascular skills to residents without any experience [17].
Angioplasty andStent Placement
Angioplasty and stenting are core procedures in vascular
interventions. Training of renal angioplasty and stenting
using the VIST-Lab (Mentice) simulator has been shown to
accelerate an apprentices’ learning curve to reach procient levels [15, 18]. Moreover, renal stenting outcomes
when tested on the ANGIO Mentor (Simbionix 3D Systems
simulator) improved after training on the simulator, showing technical skill improvement and increased patient
safety [19]. All main vendors developed simulation training programs for major vasculature stenting. For example,
carotid artery stenting results evaluated with the VIST-Lab
(Mentice) simulator improved after novices’ simulation
training [20].
Simulator training should be performed in a stepwise
fashion, from the basic to more complex procedure. For
example, the trainee will practice iliac artery stenting prior to
2 Simulation Training inInterventional Radiology
11
supercial femoral artery angioplasty and stenting procedures, which results in better scores on the ANGIO Mentor
(Simbionix 3D Systems) endovascular simulator [21, 22].
Simulation of stenting can be used for more than just gaining
general skills, but procedures can be rehearsed on the ANGIO
Mentor simulator based on pre-acquired CTA of a patient
prior to performing a procedure on the same patient [23, 24].
It was reported that patient-specic rehearsals resulted in
better simulation scores [21], and these rehearsals could, in
some instances, lead to changes in the patient’s procedural
plan [24].
Endovascular Aneurysm Repair
Training for medical procedures and surgery requires the
adoption of a wide range of unique skills which include an
in-depth understanding of anatomy and anatomic variations,
tools and devices, logistical planning, complication avoidance, and haptic feedback. For these reasons, procedural and
surgical simulators are particularly appealing for procedural
training, prociency assessment, and skill optimization.
Surgical simulators have already been explored for sinus surgery [25], as well as gynecologic [26] and urology procedures [27].
There is early evidence supporting the role of simulators
for endovascular aneurysm repair (EVAR) [28–31]. Potential
advantages include improved safety (reduced radiation exposure, contrast media usage, and procedure time) [31], technical readiness (anticipate and prevent complications, optimize
device and graft selection and sizing, assist in selection of
ideal working projection) [30], and enhanced decision making and condence in real procedures. While not yet proven,
this may translate to nancial improvement through fewer
complications and resulting shorter patient stays or readmissions. Most importantly, the educational value in training
inexperienced operators is immeasurable; an unlimited
library of training cases representing specic care challenges
can be developed and utilized for physician training.
The simulator is positioned on a table or gurney so that
two operators can stand on both sides of the “patient” for the
simulated procedure, also called procedure “rehearsal”
(Fig.2.3). Simulators generally use patient-specic CT data
to create a fully interactive uoroscopic simulation of anatomy. Images can be displayed in a typical uoroscopic mode
or with bony overlay. In addition, 3-dimensional modeling
can be displayed (Fig.2.4) both for endograft planning and
treatment rehearsal. The simulator has specic aneurysm
graft data embedded in the software planning, allowing digital selection of both specic graft manufacturers as well as
sizes and congurations. For instance, evenbranched and
fenestrated grafts have becomeavailable recentlyon the 3D
Systems (Tel Aviv, Israel) simulator to rehearse these often
complex procedures that might benet from practice prior to
actual live performance.
3D Systems (formerly Simbionix) platform (Tel Aviv,
Israel) has two access “limbs” or ports through which each
operator can insert blunt-ended catheters and a stiff wire that
then appear and perform on the monitor as the digitally
selected device. Selectable devices that can be simulated
include sheaths, wires, shaped catheters, and endografts. The
torque response of devices is generally 1:1, representing a
potential limitation compared to actual procedures in which
patient anatomy and friction may impact catheter movement.
Similarly, there is currently no haptic feedback or force sensing function. However, the devices do respond to arterial tortuosity and diameter; in particular, grafts may shift position,
foreshorten, or lose parallax upon simulated deployment as
Fig. 2.3 Examples of
simulators. The Simbionix
percutaneous renal access
simulator (a) and the
Simbionix ANGIO Mentor
platform (b). Simbionix
ANGIO Mentor photo
courtesy of 3D Systems/
Simbionix URO-PERC
Mentor photo courtesy of 3D
Systems
12
G. Bartal and J. H. Rundback
Fig. 2.4 EVAR image displays simulated procedures. The simulator
can be used both for planning (a) and treatment simulation (b). During
planning (a), surface rendered center line images allow segmentation
and measuring for graft selection; a spindle view (top right panel) and
corresponding axial image (bottom right panel) allow accurate cross-
sectional diameter measurements at every level. During procedure
rehearsal (b), patient level CT data (bottom left) is shown along with
either a 3-dimensional surface rendered landscaped view (middle
panel) or traditional contrast-enhanced uoroscopic rendering (right
panel)
2 Simulation Training inInterventional Radiology
13
they would in real life. The individual controlling the input
on the monitor can make “quick” adjustments for modifying
device selection or sheath position without completely
removing the catheters from the machine.
Operators have access to “table side” controls including
uoroscopic and C-arm projection. An electronic syringe can
be attached to catheters to create an angiographic run during
depression of the syringe plunger. There are handles and
controlsfrom manufacturers that look, feel, and respond like
the deployment mechanisms of real grafts on separate insertable catheters.
Clinical Applications
Aortic Procedures Planning
The simulation workow is as follows:
1. Obtain a contrast-enhanced computed tomographic
angiogram (CTA) on the patient and send the CT data to
the simulation platform.
2. Use the platform to perform center line measurements
and endograft selection.
3. Perform independent graft planning and selection using
customary techniques (often from the axial CT data
alone), then compare the planning notes and possible
strategies.
4. Rehearse the EVAR on the simulator using the different
strategies and endograft congurations.
5. Modify the actual treatment plan based upon observations
during rehearsal.
6. Order the desired grafts.
7. Proceed with the actual live EVAR.
Inherent in this workow is the ability to make multiple
modications in device and treatment strategy prior to
actual procedure performance. In our experience, there
have been three important facets of EVAR affected by procedure rehearsal: the selection of optimal angles to be used
for endograft positioning and deployment, graft and component sizing and selection, and identifying the best obliquity for cannulation of the contralateral limb. While
third-party software options exist to perform center-line
imaging that may support best graft selection, our experience has shown that this is not a substitute for actually “trying” a graft in a simulated system (Fig. 2.5). Aneurysm
morphologies with long distances to the aortic bifurcation
and tortuous iliac access have particularly beneted from
procedure rehearsal. In these cases, we have found that limb
lengths measured from traditional cross-sectional imaging
do not reliably determine the idealized limb length needed
to avoid type 1B endoleaks.
Preliminary data supports the subjective advantages of
EVAR procedural simulation (personal data). In an early
analysis of 43 questionnaires completed by 23 different
operators after 24 previously rehearsed EVAR procedures,
all physicians reported a positive impact of rehearsal. Using
a 10-point scale (10 being most favorable), EVAR simulation
increased perception of intra-staff collaboration effective-
Fig. 2.5 Example of
procedure simulation
changing EVAR planning.
Initial graft selection as
determined by axial CT
images resulted in a large type
1A endoleak (arrows) during
rehearsal (a). A larger
diameter graft (curved arrow)
was therefore used for the
actual procedure with
successful sealing of the
aneurysm neck (b)
14
G. Bartal and J. H. Rundback
Table 2.1 Assessment tools to evaluate trainee performance
Assessment
tool Use
Procedural
checklist
Surveys Evaluate trainees’ condence, self-efcacy, and
Global rating
scales
Pre- and
post-test
Time-action
analysis
Error analysis Rates procedural performance based on the number
Simulator
metrics
Evaluates procedural skills or steps on either a
binary or a rating scale [33–36]
comfort with the training. Also evaluates validity of
simulator [37]
Measures complex multidimensional skills such as
teamwork and communication [38, 39]
Measures the impact on the knowledge, not clinical
reasoning and decision making [40, 41]
Assess procedural skills by breaking down the
procedure into a series of steps and assessing how
long each one takes [42, 43]
and types of errors made, identifying possible errors
[44, 45]
Pre-programmed metrics to assess trainee
performance [46, 47]
ness (M=9.12, SD=1.03, median 9.00), primary operator
procedure condence (M=8.51, SD=1.4, median 9.00) and
readiness (M=8.51, SD=1.12, median 9.00), and real case
technical performance (M=8.09, SD=1.38, median 8.00).
The similarity of C-arm projections to the real procedure was
also rated high (M=8.77, SD=1.48, median 9.00).
Performance Assessment
Medical education requires assessment of knowledge, competence, performance, and action. These same skills are
applicable for evaluation of the abilities acquired with simulation [32]. Moreover, simulation can provide trainee performance assessment reports; these can be used to compare
improvement over time (Table2.1).
Medical Simulation inRadiation Dose
Management
Both trainees and experienced practitioners must maintain a
constant awareness of radiation dosage and opportunities to
minimize exposure for patients and personnel. Simulators
can allow for repeatable training so as to increase procedural
efciency, reduce complication rates, and ideally, radiation
exposure (refer to Chap. 3 for more information on radiation
safety) [38, 39].
Future Prospects
A broad lack of adoption of machine-based manual simulation remains hampered by high cost, limited availability,
and insufcient resources. Future platforms may be
limited to high-volume training centers or as a part of educational courses. Nonetheless, there remains a need for
more expeditious software development to incorporate
rapidly evolving graft designs and strategies. An additional critical component will be the engineering of better
haptic systems that provide force feedback during procedure rehearsal, since tactile sensory input is an important
aspect of anticipating device performance and avoiding
complications.
Nonmanual simulation may serve a future role as well.
Thin client software platforms without a “hands-on” component may still serve a useful role in quickly testing devices in
patient-specic anatomy. Simulators are an objective assessment tool for measuring trainee’s performance with preprogrammed metrics. Furthermore, the FDA encourages the
use of simulation for training as part of introducing new
medical device to the market. The time has come for IR’s to
embrace simulation training. Even so, further research to
evaluate simulator performance in relation to real-world
skills is still required.
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