Endovascular Simulation Training and the Venous System Initial Observations

by Mark A. Mattos, MD

The practice of vascular surgery continues to evolve and vascular surgical education and training principles must evolve with it. A host of educational challenges now exist which were not present even as short a time as 10 years ago. Alternative training paradigms (and specialties) have produced vascular interventional trainees with different lengths of operative and endovascular skills.

Increased public expectations has demanded improved clinical outcomes and more in-depth objective documentation of skills training and performance. Improved non-invasive imaging has resulted in a decreased need for selective catheterizations; increased financial stresses have placed a premium on greater speed and efficiency in the operating room/ endovascular suite resulting in greater faculty participation, less trainee independence and diminished time for teaching. Work hour restrictions have further limited the training experience of vascular trainees.

As a result of these challenges, the traditional Halstedian apprenticeship training model may no longer meet the current training needs for optimal technical skills development of the vascular trainee.

Benefits of Endovascular Simulation Training

Simulation-based endovascular training has emerged as a novel method to enhance and advance the endovascular technical skills and education of vascular trainees. Simulation training moves the learning curves of trainees out of the operating room/endovascular suite and into the surgical skills or simulation training lab. Because trainees are performing procedures using high-fidelity simulators they are provided the opportunity to make errors in a safe risk-free environment and are empowered to learn from those errors without fear of doing harm to live patients.

Simulation training has been shown to reduce trainee errors in simulated and clinical-based procedures. The use of endovascular simulator trainers allows the teaching and procedural focus to reside with the trainee and not the patient. This is exactly opposite the scenario in clinical procedures where the focus more often than not is appropriately directed towards the care of the patient and not the education of the trainee. In essence, simulation training permits trainees to undergo consequence-free learning, and as a result institutions are benefited since simulation training gives them access to liability-free training for the trainee.

Endovascular simulation training offers other benefits to both the trainee and the patient. First, endovascular simulation training is radiation-free training. There is no radiation risk to either trainee or patient and is especially beneficial for the female trainee who is pregnant, and who might wish to avoid radiation exposure during her pregnancy but desires to maintain her endovascular skill set.

Second, since endovascular simulation training is performed without radiation, there is no need to wear protective lead shielding. By avoiding having to wear lead shielding during endovascular simulation procedures, the risk of acute or chronic musculoskeletal injury to the trainee is eliminated. Third, technically speaking, endovascular simulation training can potentially increase the number of advanced technical skills learned and performed by the trainee as compared to their clinical experience.

One such example would be the ability of a trainee to achieve an increased number of selective first, second or third order arterial or venous cannulations performed during simulated endovascular procedures as compared to the number of actual selective cannulations performed in real-life clinical endovascular procedures. Simulation training can provide trainees access to new devices as well as provide device-specific training prior to using these devices on a real patient for the first time. Fourth, simulation training offers training and learning opportunities to those physician trainees who otherwise would have no available clinical pathway to learn new endovascular skill sets.

Endovascular simulation can help to standardize the training goals for trainees with different endovascular and operative experiences and skills. It can provide objective methodology and assessment metrics to evaluate the technical skills of the trainee and provide an acceptable avenue for comparison of simulated performances by trainees of the same or different specialty.

Endovascular simulation training has been used to help recruit medical students and residents into applying for careers in different interventional specialties. Simulation training and education has created new research opportunities as well as unique career pathways to young faculty members across all specialties.

And finally, the benefits of simulation training have not been lost upon our hospitals, Medicare and other third party insurance carriers. There have been several recent reports indicating that malpractice insurance carriers may ultimately set their malpractice insurance rates depending on whether or not physicians have undergone simulation training and education.

Current Status of Endovascular Venous Simulation Training

Early reports on endovascular simulation training have shown evidence of reliability, benefit for novice trainees and experienced interventionalists, improved training performance in different vessels, transfer of skills between two different target vessels, and transference of endovascular skills from the simulation trainer to the operating room or endovascular suite. However, it should be recognized that all of these studies evaluated outcomes of procedures performed only on arteries.

To date, there have been no reports on endovascular venous simulation training - until now.

Preliminary Results of Endovascular Venous Simulation Training

Endovascular venous simulation training was introduced into the Wayne State University Vascular Surgery Fellowship Training Program in December 2009. Six vascular surgery fellows received endovascular venous simulation training.

Simulated venous procedures procedures were performed using a Procedicus VIST (Vascular Interventional Systems Trainer) 7.5 endovascular simulator (Mentice Inc., Gothenburg, Sweden). All simulation procedures were proctored by the author with immediate formative feedback to the fellows. A total of 118 simulated non-selective diagnostic inferior vena cavagrams, 236 simulated selective renal vein venograms and 105 simulated inferior vena cava (IVC) filters were placed. In comparison, since December 2009, 30 non-selective inferior vena cavagrams, no selective renal vein venograms and placed 30 IVC filters were placed by the fellows in real-life patients (p<0.001).

The range of diagnostic venography and IVC filter placement per fellow ranged from 16 to 22 and 14 to 20 procedures, respectively. Comparison of combined first to final simulated inferior vena cavagram, renal vein venography and IVC filter placement procedure results indicated significantly higher procedural checklist (quantitative assessment) and global rating scale scores (qualitative assessment) for all final simulated procedures (p<0.05) (instructional effectiveness).

Decreased combined total procedure time, fluoroscopy time, and time to IVC filter placement were noted at all final simulated venous procedures. Combined wire, catheter, and fluoroscopic errors were significantly reduced by the final simulated venous procedure (p<0.005).

Comments by Wayne State University Vascular Surgery Fellows

All of the vascular surgery fellows who participated in the simulation training program believed that endovascular venous simulation training was a useful educational component and improved their quality of learning. They responded that their endovascular skill sets and confidence in performing diagnostic venography and IVC filter placement were improved as a result of their simulation training experience and they desired more time to train using the simulator.

It was clear that nearly all of the fellows believed that the quality of learning was improved when the structured endovascular simulation training curriculum was coupled with the availability of immediate formative feedback and enhanced the overall learning experience.

Furthermore, the greatest benefit of endovascular simulation training was observed for those simulated procedures the fellows performed the least frequently in the clinical setting. The fellows rated the Mentice Procedicus VIST endovascular simulator as being useful for acquiring both basic and advanced endovascular venous skills.

They reported the simulated anatomy for the venous system as being realistic enough for training, and indicated that the instruments and devices used during the simulated venous procedures displayed the appropriate degree of haptic tactile feedback.


This represents our initial experience in endovascular venous simulation training. The endovascular skills of
vascular surgery fellows performing simulated diagnostic venography and IVC filter placement improved significantly over the length of the structured endovascular simulation training period. The endovascular venous simulation training provided the fellows with the opportunity to perform a far greater number of nonselective selective venous cannulations and IVC filter placements as compared to the number of similar procedures performed on real-life patients.

The vascular surgery fellows collectively indicated that the presence of a structured endovascular simulation training curriculum enhanced their endovascular education, increased their technical skills and procedural confidence, and was most beneficial for those endovascular procedures they performed the least frequently. Finally, it was noted that the Mentice Procedicus VIST served as a reliable and effective endovascular simulation trainer for diagnostic and therapeutic venous procedures.


In conclusion, our initial experience whith endovascular venous simulation training indicates that this type of technical skills training provided a greater breadth of endovascular education and training in the vena cava and selected veins than what could be obtained through clinical training alone. Our vascular surgery fellows believed that endovascular venous simulation training provided great training value and suggested that it should become an integral part of vascular surgery training programs.

Addition of further supra-inguinal venous procedures was suggested to further enhance the content of the endovascular venous simulation training curriculum. Specifically, we recommend that the simulation industry develop additional endovascular venous simulation modules to accommodate education and training for iliac vein balloon angioplasty, iliocaval stenting, mechanical and pharmacologic thrombolysis and pelvic vein embolization.