Endovascular embolisation has evolved considerably over the last two decades, and new innovative technologies have become an important catalyst to the growth of this field.
With improvements in microcatheters, imaging modalities, and embolic materials, the application of embolisation has spread across a wide range of treatment areas, including oncology, trauma, endovascular therapy, uterine fibroids, and emergency bleeding.
With this in mind, the inaugural Global Embolization Symposium and Technologies (GEST) meeting was held in Barcelona, Spain, from April 25-27, 2007, and organised by Drs Jafar Golzarian (Iowa, US), Ziv Haskal (NY, US) and Marc Sapoval (Paris, France).
Almost 700 delegates attended the meeting, which focused exclusively on the role of embolisation across certain interventional therapy areas.
UAE: The next frontier in virtual reality simulation training
The emergence of virtual reality simulation has revolutionised both training and practice of interventional radiology in recent years. It has provided robust, high-quality training and has assured the patient of the interventional radiologist's proficiency and spared the early learning curve of trainees as well as allowing established interventional radiologists to learn new skills and techniques.
The term 'virtual reality' refers to 'a computer-generated representation of an environment that allows sensory interaction, thus giving the impression of actually being there,' and that the primary goal of training is to improve the efficiency of the procedure and to reduce errors resulting in better patient care. According to Professor Jim Reekers, Amsterdam, The Netherlands, in surgical training there was a mindset, 'see one, do one, teach one.' However, virtual reality simulation has brought about a paradigm shift of 'see one, simulate many, do one competently, teach everyone'. Until recently many of these skills have been restricted to vascular procedures such as iliac, superficial femoral artery and renal intervention.
"Interventional radiology techniques are not related to any 'classical' vascular surgical techniques," commented Reekers, at the recent GEST meeting. "The traditional method of training is disappearing because other diagnostic methods have became available replacing routine diagnostic angiography."
With this in mind, Reekers claimed that there has been a paradigm shift away from vascular towards embolisation simulation. Of course, interventional radiologists are perfectly suited to learn embolisation techniques via virtual reality simulation as they have many years of catheter practice, much better suited for example than a gynaecologist who wants to learn uterine artery embolisation (UAE) but who has no catheter experience.
Reekers then outlined a training programme for virtual reality simulation for UAE. He said that any programme must have a dedicated curriculum with objective outcome parameters. 'Training by Reality' must be a step-by-step process where operators learn from experience, building up a level of confidence: "Before an in interventional radiologist wants to learn a new procedure, it must be decided who we want to train, what do we want to teach, how are we going to teach, what are the goals to achieve and how are we going to evaluate these goals?"
Evaluation of training
As a result, he called for efficient assessment tools to evaluate whether the training is effective, time-action analysis, knowledge transfer and established clinical outcomes. In proposing a virtual reality simulation embolisation programme, Reekers outlined the skills and techniques that would be taught in order for an interventional radiologist to perform embolisation procedure to a high standard. These skills included, but were not limited too:
• Loosing a coil
• Anchoring coils
• Dislodging of the guiding catheter
• Dislodging of the selective catheter
• Plugging of the catheter
• Reflux
• Non-target embolisation
• Utilising different embolic agents
The cirriculum for embolisation should incorporate ten virtual reality sessions (30 minutes) five with a tutor and five as first operator, under a one-to-one tutorship with certification for this procedure. These virtual reality sessions would be in conjunction to learning through text books, teachers, courses, meetings and fellowships.
Problems and limitations
Reekers did however claim that some issues surrounding virtual reality simulation and training have not yet been addressed such as the effectiveness of virtual reality trainers in interventional radiology (transfer of knowledge). He also highlighted that experience on a simulator cannot yet be regarded as equivalent to training and that it should be self-evident that even a valid simulation that predicts transfer of a specific skill to the procedural setting has its limitations.
He concluded be saying that virtual reality simulation provides more questions than answers, however, this should not diminished from the fact that it has great potential: "It must be remembered that virtual reality is not a stand-alone training tool and should only be used within a specific training curriculum, with professional supervision, defined goals and proper evaluation."
The French experience
Following Reekers, Jean-Michel Baroli, Marsaille, France, discussed the French approach to training and embolisation. He began by stating that although interventional radiology is developing fast in the major centres interventional procedures are unequally distributed in the different regions of France, especially embolisation.
Currently, the Inter-University Diploma (DIU) of cardiovascular imaging is taught in 12 French universities and the progamme is based on two years with one diagnostic option and one therapeutical and interventional option. There is no specific embolisation teaching programme for the DIU (focused mainly on angioplasty and atherosclerosis). However, to overcome these shortcomings the Société Française d'Imagerie CardioVasculaire (SFICV) has organised the School of Embolization, and its mission is to:
• Ensure that the technical aspects of embolisation procedures are taught in all the medical schools in France;
• Make the procedures easier to understand;
• Ensure each university hospital has a range of specific skills according to local competences in clinical practice; and
• To enable young interventional radiologists extend their skills to all areas of embolisation except interventional neuro-radiology.
Twelve students per year who aim to become interventional radiologists (end of residency or assistant lecturers) are selected by their head of department and attend a one-week intensive teaching programme (ten hours per day), consisting of lectures, clinical cases, test bench and virtual reality. Baroli said that the interactive teaching is supervised by the same tutor for the whole session to ensure that the course content is seamless, homogenous and interactive with the teaching staff.
The School also has five industrial partners (Boston Scientific, Cordis, Biosphere Medical, Cook Medical and Terumo), who believe the School is an exceptionnal opportunity for them to make contact with the future generation of interventional radiology in the field of embolisation and support them in their career.
Baroli said the School of Embolization does not currently award a diploma, however, from 2008 the School will be participate in the vascular and interventional DIU teaching programme. He concluded that the emergence of embolisation procedures follows a current trend in clinical practice, are developing fast and becoming a major part of routine activity, and therefore warrant a specific teaching programme.
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