Post on 25-May-2020
The Role of Virtual Reality Simulations in Endovascular Procedure Training 1
The Role of Virtual Reality Simulations in Endovascular Procedure Training
Kareem Albaba
Indiana University School of Medicine
The Role of Virtual Reality Simulations in Endovascular Procedure Training 2
Abstract
This paper aims to explore the existing literature to identify the current role of virtual reality
(VR) simulations in endovascular procedure training. First, we examine the validity of medical
simulations for training before we focus on the current use across medical education. Finally, we
examine the current use of VR in interventional radiology (IR) training and outline the necessary
steps for continued innovations in the field.
The Role of Virtual Reality Simulations in Endovascular Procedure Training 3
Introduction
While the rise of endovascular surgery represents an evolution of traditional open surgery
through the marriage of technology and medicine, endovascular training has remained subject to
the same apprenticeship structure espoused by William Halsted in his development of the first
surgical residency training program at Johns Hopkins in the late 19th century. As elaborated by
Desser, the “current medical education framework…is based on the premise that trainees will
obtain the necessary expertise by observing and working closely with expert practitioners”
(2007). However, more recently, researchers have shown that “within the area of skill
acquisition, it is widely accepted that visual observation alone does not lead to proficiency but
that repeated deliberate practice is indispensably necessary for skill development, improvement,
and maintenance” (Johnson et al. 2011).
While deliberate practice is the preferred method of medical training, its use is stymied in
procedural specialties where there is an upper limit to the number of available procedures—this
is exacerbated by limitations in duty hours for trainees, the increased incidence of outpatient
procedures and the diminishing of “the public’s tolerance for being the ‘guinea pigs’ while
trainees gain clinical experience” (Dresser 2007). Whereas in non-procedural specialties these
limitations can be overcome through the use of standardized patients, “the use of live volunteers
for hands-on training in surgical and radiologic procedures (especially those that involve the
placement of implants) is impossible” (Bott et al. 2011).
To address these concerns, “the American College of Surgeons developed support for the
use of simulation-based training in a variety of settings,” particularly because “the use of well-
designed simulations permits the learner to be trained in a controlled environment without
compromising safety and patient outcomes, allows exposure to challenging and complex events
The Role of Virtual Reality Simulations in Endovascular Procedure Training 4
in a controlled setting, and allows practice until perfection” (Schirmer et al. 2013). This parallels
the field of aviation, where many of the same concerns come into play and “teamwork training
with simulation has been instrumental in reducing errors” (Schirmer et al. 2013). Just as pilots
practice extensively on simulators before ever entering the cockpit of a plane, “simulation
exercises provide medical trainees with hands-on experience and have the potential to accelerate
learning dramatically, particularly early in training, without exposing patients to any risk”
(Desser 2007).
Validity of Simulators in Medical Training
The overall usefulness of simulations in medical training is important to confirm before
investment into the development of high-fidelity simulators and their integration into curricula—
high costs and the possibility of insufficient or detrimental training necessitate an accurate
understanding of the benefits and risks of their implementation. In a systematic review by
Issenberg et al. cited by Gould, 109 published studies were examined to determine “whether
medical simulation facilitates learning” (2007). Gould summarizes the findings as follows:
“[The] best available evidence did show a benefit for simulation when the following
conditions are met: (a) educational feedback is provided, (b) learners are given the
opportunity for repetitive practice, (c) tasks range in difficulty, and (d) the exercises
based on the simulation are integrated into the curriculum.” (2007)
Generally, “learning by playing seems to be a solid method to gain better appropriation for the
learner…[they] seem to better enable the learner to feel immersed, to improve their confidence,
and to enhance their clinical skills” (Gautier et al. 2016).
The Role of Virtual Reality Simulations in Endovascular Procedure Training 5
Focusing on software-based virtual reality (VR) simulators, more recent studies have
shown mixed results concerning their efficacy. For example, research done on an ultrasound
simulator “showed that the simulator improved residents’ abdominal and pelvic scanning
technique, as well as their self-assessment scores,” prompting the researchers to “[conclude] that
the simulator was useful for both training and the evaluation of residents’ performance” (Desser
2007). Similarly, simulation software aimed at teaching transvaginal ultrasound techniques to
obstetrical and gynecological residents “[suggested] the superiority of a single virtual reality
simulation training session over a single session of theoretical teaching of the same duration” in
unexperienced operators” (Chao et al. 2015). On the other hand, a comparison of “laparoscopic
surgery performance on real-life pigs for a group of surgical residents who received training on a
VR surgical simulator with a control group that did not receive any simulator training…did not
provide evidence for the training effectiveness of the simulator, with no significant performance
differences between the two groups” (Johnson et al. 2011).
Overarching considerations relevant to the development of include “an assessment of the
quality, comprehensiveness, usability, and acceptability of the contents to users” as well as a
determination as to “whether the result of its use is an improvement in learning beyond that
achieved with traditional training or other computer-based training systems” (Bott et al. 2011).
Because of this, the integration of VR simulations is sparse in current medical training despite
confirmation of their validity in teaching. This is also in part due to the lack of totality in
teaching all aspects of procedural care—for example, “existing surgical simulators, both part task
and procedural, are primarily focused on the development of psychomotor skills” and “offer little
training in cognitive skills associated with higher level mental functions related to workload
The Role of Virtual Reality Simulations in Endovascular Procedure Training 6
management, planning, communication, decision-making and problem-solving”
(Sankaranarayanan et al. 2015).
The Adoption of Virtual Reality Simulations in Interventional Radiology Training
Use of VR simulations in endovascular training for interventional radiologists is an area
that is rapidly expanding following studies that “have demonstrated the efficacy and validity of
endovascular simulators” and prompting the European Virtual Reality Endovascular Research
Team to “systematically [study] different components of the use of endovascular simulators and
[find] them valid and useful if used within a structured curriculum” (Schirmer et al. 2013). Their
use in endovascular training has also been encouraged by the FDA, with a recent “decision to
approve one manufacturer’s carotid stent, contingent on the company’s devising a training
system that did not put patients at risk” that “set a precedent and provided a major impetus for
the development of endovascular simulators” (Desser 2007).
Trials specific to endovascular procedures have shown positive results similar to those
seen in ultrasound and laparoscopic procedure training—an examination of commercial VR
simulators such as virtX showed “a positive short-term effect of simulation-based training in
radiology, but the long-term effects of such training on knowledge internalization are as yet
unknown” (Bott et al. 2011). Similarly, a randomized trial was performed by Chaer et al.
“examining transfer of VR endovascular training (iliofemoral angioplasty) to the human
model”—results showed “significantly improved performance that was rated with use of a
procedure-specific checklist and a global rating scale” (Ahmed et al. 2010). This also informs the
necessity of expert involvement in the development of the simulations—the development of an
accurate simulations that “[permits] valid modeling and assessment of tasks while reducing the
The Role of Virtual Reality Simulations in Endovascular Procedure Training 7
risk of training inappropriate or incorrect skills…[needs] detailed information about what it is
that the clinician is actually doing during a real procedure” (Gould 2007).
“Gen2-VR simulator showing the physical interface (left) and the immersive virtual environment (right) with the user represented as
an avatar” (Sankaranarayanan et al. 2015).
Once the direction of the simulation is determined by consultation with a subject-matter
expert, the simulation should focus on realism to add validity—as such, “accurate models of
individual variations in anatomy and pathology should be available, and dynamic models of
vessel wall behavior are needed” (Dankelman et al. 2004). However, certain technical aspects of
model implementation are “still very difficult to achieve in VR,” such as “realistic simulation of
the interaction of the instrument with the vascular wall and rendering of all kinds of pathological
conditions” (Dankelman et al. 2004). A high-fidelity simulation is therefore still plagued by
technical difficulties regardless of validity and usefulness, and the development of such “a full-
The Role of Virtual Reality Simulations in Endovascular Procedure Training 8
scale interventional simulator is very costly, and its effectiveness will be difficult to evaluate”
(Dankelman et al. 2004).
While current implementations are plagued by “reduced tactile feedback (haptics), lack of
case-by-case variety, and lack of exact replication of fine motor skills,” VR simulations can
supplement current training methods by providing “an early endovascular training
experience…with the advantage of objective assessment of performance” (Ahmed et al. 2010).
Improvements in processing power, haptics and the ubiquitous nature of commercial VR
platforms provided by the Oculus Rift and Microsoft Hololens will only accelerate the
development and integration of high-fidelity simulations in the training of interventional
radiologists.
The Role of Virtual Reality Simulations in Endovascular Procedure Training 9
References
Ahmed K, Keeling AN, Fakhry M, et al. Role of Virtual Reality Simulation in Teaching and
Assessing Technical Skills in Endovascular Intervention. J Vasc Interv Radiol.
2010;21(1):55-66. doi:10.1016/j.jvir.2009.09.019.
Bott OJ, Dresing K, Wagner M, Raab B-W, Teistler M. Informatics in Radiology: Use of a C-
Arm Fluoroscopy Simulator to Support Training in Intraoperative Radiography.
RadioGraphics. 2011;31(3):E65-E75. doi:10.1148/rg.313105125.
Casey DB, Stewart D, Vidovich MI. Diagnostic coronary angiography: initial results of a
simulation program. Cardiovascular Revascularization Medicine. 2016;17(2):102-105.
doi:10.1016/j.carrev.2015.12.010.
Chao C, Chalouhi GE, Bouhanna P, Ville Y, Dommergues M. Randomized Clinical Trial of
Virtual Reality Simulation Training for Transvaginal Gynecologic Ultrasound Skills.
Journal of Ultrasound in Medicine. 2015;34(9):1663-1667.
doi:10.7863/ultra.15.14.09063.
Coles T, John NW, Gould DA, Caldwell DG. Haptic Palpation for the Femoral Pulse in Virtual
Interventional Radiology. In: IEEE; 2009:193-198. doi:10.1109/ACHI.2009.61.
Dankelman J, Wentink M, Grimbergen CA, Stassen HG, Reekers J. Does Virtual Reality
Training Make Sense in Interventional Radiology? Training Skill-, Rule- and
Knowledge-Based Behavior. Cardiovasc Intervent Radiol. 2004;27(5):417-421.
doi:10.1007/s00270-004-0250-y.
Desser TS. Simulation-Based Training: The Next Revolution in Radiology Education? Journal of
the American College of Radiology. 2007;4(11):816-824. doi:10.1016/j.jacr.2007.07.013.
The Role of Virtual Reality Simulations in Endovascular Procedure Training 10
Gautier JE, Bot-Robin V, Libessart A, Doucède G, Cosson M, Rubod C. Design of a Serious
Game for Handling Obstetrical Emergencies. JMIR Serious Games. 2016;4(2):e21.
doi:10.2196/games.5526.
Gould DA, Reekers JA, Kessel DO, et al. Simulation Devices in Interventional Radiology:
Validation Pending. J Vasc Interv Radiol. 2009;20(7):S324-S325.
doi:10.1016/j.jvir.2009.04.014.
Gould DA. Interventional Radiology Simulation: Prepare for a Virtual Revolution in Training. J
Vasc Interv Radiol. 2007;18(4):483-490. doi:10.1016/j.jvir.2006.11.005.
Johnson SJ, Guediri SM, Kilkenny C, Clough PJ. Development and Validation of a Virtual
Reality Simulator. Human Factors. 2011;53(6):612-625.
doi:10.1177/0018720811425042.
Middleton RM, Alvand A, Garfjeld Roberts P, Hargrove C, Kirby G, Rees JL. Simulation-Based
Training Platforms for Arthroscopy: A Randomized Comparison of Virtual Reality
Learning to Benchtop Learning. Arthroscopy: The Journal of Arthroscopic & Related
Surgery. January 2017. doi:10.1016/j.arthro.2016.10.021.
Mitha AP, Almekhlafi MA, Janjua MJJ, Albuquerque FC, McDougall CG. Simulation and
Augmented Reality in Endovascular Neurosurgery. Neurosurgery. 2013;72:A107-A114.
doi:10.1227/NEU.0b013e31827981fd.
Sankaranarayanan G, Li B, Manser K, et al. Face and construct validation of a next generation
virtual reality (Gen2-VR) surgical simulator. Surg Endosc. 2015;30(3):979-985.
doi:10.1007/s00464-015-4278-7.
Schirmer CM, Mocco J, Elder JB. Evolving Virtual Reality Simulation in Neurosurgery.
Neurosurgery. 2013;73:S127-S137. doi:10.1227/NEU.0000000000000060.
The Role of Virtual Reality Simulations in Endovascular Procedure Training 11
Wu F, Chen X, Lin Y, et al. A virtual training system for maxillofacial surgery using advanced
haptic feedback and immersive workbench. Int J Med Robot. 2013;10(1):78-87.
doi:10.1002/rcs.1514.