Semaphorin 7a exerts pleiotropic effects to promote breast tumor progression.

Understanding what drives breast tumor progression is of utmost importance for blocking tumor metastasis; we have identified that semaphorin 7a is a potent driver of ductal carcinoma in situ (DCIS) progression. Semaphorin 7a is a glycophosphatidylinositol membrane-anchored protein that promotes attachment and spreading in multiple cell types. Here, we show that increased expression of SEMA7A occurs in a large percentage of breast cancers and is associated with decreased overall and distant metastasis-free survival. In both in vitro and in vivo models, short hairpin-mediated silencing of SEMA7A reveals roles for semaphorin 7a in the promotion of DCIS growth, motility and invasion as well as lymphangiogenesis in the tumor microenvironment. Our studies also uncover a relationship between COX-2 and semaphorin 7a expression and suggest that semaphorin 7a promotes tumor cell invasion on collagen and lymphangiogenesis via activation of ß1-integrin receptor. Our results suggest that semaphorin 7a may be novel target for blocking breast tumor progression.

Rationalising cross-match requests in vascular surgery is safe and cost effective.

This study describes how a vascular centre rationalised their blood transfusion policy. A multidisciplinary panel reviewed data for blood transfusion protocols and implemented improvements that were analysed. The number of units cross-matched fell from 272 to 183 over a six month period. Unused blood reduced from 80% to 61%. The study concluded that rationalisation of cross matching policies is safe and provides cost and resource benefits.

Endoscopic vein harvesting in lower extremity arterial bypass: a systematic review.

OBJECTIVE: Endoscopic vein harvesting (EVH) for arterial bypass surgery may be associated with lower wound complication rates than open vein harvesting (OVH), but other long-term outcomes remain controversial, and there are concerns that graft patency may be poorer after EVH compared with OVH. We conducted a systematic review of all available evidence for EVH in lower extremity arterial bypass (LEAB). METHODS: A literature search of Medline, Embase, Ovid and Cochrane databases between 1996 and 2013 was performed using the terms "endoscopic vein harvesting", "minimally invasive vein harvest", "peripheral bypass surgery", and "lower extremity bypass surgery", and detailed in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Primary outcomes were graft patency and overall wound complication rates. Secondary outcomes were wound infection, length of hospital stay, and cost-effectiveness. Summary estimates were calculated by random effects meta-analysis if sufficient data were available. RESULTS: We identified 18 cohort studies and case series, with considerable clinical heterogeneity, including 2,343 patients. Meta-analysis of six studies revealed a significantly reduced rate of primary patency after EVH (hazard ratio 1.29, 95% confidence interval [CI] 1.03-1.63), with no significant difference between EVH and OVH with respect to wound infection in 12 studies (odds ratio 0.81, 95% CI 0.61-1.08). There was a lack of strong evidence to support the secondary outcomes of EVH. CONCLUSION: EVH reduces primary patency rates after LEAB, but does not demonstrate an advantage with respect to postoperative wound complications. However, the available data are heterogeneous, and uncertainty is introduced by both evolution in technology and increasing technical experience. EVH should be used with caution and in the context of formal research.

Operator-controlled imaging significantly reduces radiation exposure during EVAR.

INTRODUCTION: Adoption of endovascular aneurysm repair (EVAR) has led to significant reductions in the short-term morbidity and mortality associated with abdominal aortic aneurysm (AAA) repair. However, EVAR may expose both patient and interventionalist to potentially harmful levels of radiation, particularly as more complex procedures are undertaken. The aim of this study was to assess whether changing from radiographer-controlled imaging to a system of operator-controlled imaging (OCI) would influence radiation exposure, screening time or contrast dose during EVAR. METHOD: Retrospective analysis identified patients that had undergone elective EVAR for infra-renal AAA before or after the change to operator-controlled imaging. Data were collected for radiation dose (measured as dose area product; DAP), screening time, total delivered contrast volume and operative duration. Data were also collected for maximum aneurysm diameter, patient age, gender and body mass index. RESULTS: 122 patients underwent EVAR for infra-renal AAA at a single centre between January 2011 and December 2011. 57 of these were prior to installation of OCI and 65 after installation. Median DAP was significantly lower after installation of OCI (4.9 mGy m(2); range 1.25-13.3) than it had been before installation (6.9 mGy m(2); range 1.91-95.0) (p = 0.005). Median screening times before and after installation of OCI were 20.0 min and 16.2 min respectively (p = 0.027) and median contrast volumes before and after the change to OCI were 100 ml and 90 ml respectively (p = 0.21). CONCLUSION: Introduction of operator-controlled imaging can significantly reduce radiation exposure during EVAR, with particular reduction in the number of 'higher-dose' cases.

Unselected percutaneous access with large vessel closure for endovascular aortic surgery: experience and predictors of technical success.

INTRODUCTION: The effectiveness of percutaneous access with large vessel closure (pEVR) in non-selective groups of patients undergoing endovascular aneurysm repair (EVR) remains unclear. This study aims to identify factors that predict success in pEVR, performed using percutaneous access and the Prostar XL (Abbott Vascular, Redwood City, Calif) closure device. METHOD: Consecutive patients who underwent pEVR between April 2010 and March 2011 were identified from a prospectively maintained database. Procedural and postoperative outcomes were compared with consecutive patients who underwent endovascular aneurysm repair using standard open femoral access between April 2008 and March 2009. To determine the predictors of technical success of pEVR, the association between clinical, anatomical and procedural variables with technical success, were examined in a multiple logistic regression model. RESULTS: pEVR was attempted in 186 common femoral arteries (CFAs) with a technical success rate of 95.2% (177/186). Conventional open femoral access in the historic control group was performed in 208 CFAs. pEVR was associated with a reduced operation length (131 min [105-152] versus 150 min [124-195], p≤0.001) and length of stay (2 days [2-5] versus 4 days [2-7], p = 0.01) in patients undergoing infrarenal EVR. In secondary analysis of outcomes following percutaneous access in 91 CFAs, pre-operative renal failure, CFA depth (min and max), CFA diameter (min and max) and operator experience predicted success of percutaneous access in univariate analysis. Operator experience was the only independent predictor of technical success (p = 0.05) after adjustment for all confounding variables. CONCLUSION: pEVR using the Prostar XL device is effective in the majority of patients. In this study there were benefits in terms of reduced postoperative complications, shorter procedures and decreased lengths of stay. Operator experience is a predictor of technical success for pEVR, irrespective of clinical and morphological characteristics at baseline.

Staged visceral bypass with aortic relining for thoracoabdominal aneurysms: future perspectives.

Hybrid procedures for the repair of thoracoabdominal aneurysms have become more widely reported in the literature in the past few years. This procedure was developed as an alternative to the traditional method of open thoracoabdominal repair in the absence of a viable total endovascular solution for all cases. The early results of the procedure encouraged more centers to use a hybrid solution in the treatment of complex aortic pathology. This article evaluates the current status of this procedure and future developments.

Rapid, transient effects of the protein kinase C activator phorbol 12-myristate 13-acetate on activity and trafficking of the rat high-affinity choline transporter.

Cholinergic neurons rely on the sodium-dependent choline transporter CHT to provide choline for synthesis of acetylcholine. CHT cycles between cell surface and subcellular organelles, but little is known about regulation of this trafficking. We hypothesized that activation of protein kinase C with phorbol ester modulates choline uptake by altering the rate of CHT internalization from or delivery to the plasma membrane. Using SH-SY5Y cells that stably express rat CHT, we found that exposure of cells to phorbol ester for 2 or 5 min significantly increased choline uptake, whereas longer treatment had no effect. Kinetic analysis revealed that 5 min phorbol ester treatment significantly enhanced V(max) of choline uptake, but had no effect on K(m) for solute binding. Cell-surface biotinylation assays showed that plasma membrane levels of CHT protein were enhanced following 5 min phorbol ester treatment; this was blocked by protein kinase C inhibitor bisindolylmaleimide-I. Moreover, CHT internalization was decreased and delivery of CHT to plasma membrane was increased by phorbol ester. Our results suggest that treatment of neural cells with the protein kinase C activator phorbol ester rapidly and transiently increases cell surface CHT levels and this corresponds with enhanced choline uptake activity which may play an important role in replenishing acetylcholine stores following its release by depolarization.

Assessment of surgical competence at carotid endarterectomy under local anaesthesia in a simulated operating theatre.

BACKGROUND: Methods of surgical training that do not put patients at risk are desirable. A high-fidelity simulation of carotid endarterectomy under local anaesthesia was tested as a tool for assessment of vascular surgical competence, as an adjunct to training. METHODS: Sixty procedures were performed by 30 vascular surgeons (ten junior trainees, ten senior trainees and ten consultants) in a simulated operating theatre. Each performed in a non-crisis scenario followed by a crisis scenario. Performance was assessed live by means of rating scales for technical and non-technical skills. RESULTS: There was a significant difference in technical skills with ascending grade for both generic and procedure-specific technical skill scores in both scenarios (P < 0.001 for all comparisons). Similarly, there was also a significant difference in non-technical skill with ascending grade for both scenarios (P < 0.001). There was a highly significant correlation between technical and non-technical performance in both scenarios (non-crisis: r(s) = 0.80, P < 0.001; crisis: r(s) = 0.85, P < 0.001). Inter-rater reliability was high (alpha > or = 0.80 for all scales). CONCLUSION: High-fidelity simulation offers competency-based assessment for all grades and may provide a useful training environment for junior trainees and more experienced surgeons.

Long-term surveillance with computed tomography after endovascular aneurysm repair may not be justified.

BACKGROUND: There is a common perception that a large number of secondary interventions are needed following endovascular aortic aneurysm repair. METHODS: Prospective data were collected for a cohort of 417 consecutive elective patients undergoing infrarenal aortic endograft repair between April 2000 and May 2008. The rate of secondary interventions, associated morbidity and need for reintervention following surveillance imaging were analysed. RESULTS: The male : female ratio was 11 : 1, median age 76 (range 40-93) years and median aneurysm diameter 6.1 (5.3-11) cm. The overall 30-day mortality rate was 1.7 per cent (seven of 417). Secondary interventions were performed in 31 patients (7.4 per cent), of which six (1.4 per cent) were detected by surveillance. Endoleaks requiring reintervention occurred in 12 patients (2.9 per cent; ten type I and two type III endoleaks). Limb ischaemia secondary to graft occlusion occurred in 17 patients (4.1 per cent); extra-anatomical bypass was needed in 15 patients (3.6 per cent) and the remaining two had an amputation. Graft explantation following late infection was required in two patients (0.5 per cent). CONCLUSION: Endoluminal repair of infrarenal aortic aneurysms can be performed with a low reintervention rate. The value of prolonged surveillance seems limited and current surveillance protocols may require revision.

Is endovascular repair of mycotic aortic aneurysms a durable treatment option?

OBJECTIVE: Endovascular repair for degenerative aortic aneurysms is well established, but its role in those with infective pathology remains controversial. This study aims to assess the durability of endovascular repair with a review of our midterm results. METHOD: A retrospective analysis of a prospectively maintained endovascular database (1998-2008) was conducted, which identified 673 consecutive patients with aortic aneurysms. RESULTS: Nineteen patients (2.8%) were identified with infected aortic aneurysms, in which there were a total of 23 separate aneurysms (16 thoracic and seven abdominal). Six patients (32%) presented with rupture. Eleven patients (58%) had received antibiotics preoperatively for a median duration of 11 days (1-54 days). Fifteen of the 19 (79%) had positive blood cultures, with Staphylococcus aureus being the most common organism. All 19 patients underwent endovascular repair. There were three Type I endoleaks (one requiring conversion to open repair) and two Type II endoleaks. One patient developed transient paraplegia, resolved by cerebrovascular fluid (CSF) drainage, and one patient had a stroke. The 30-day mortality was 11%, and survival at median follow-up of 20 months (0-83 months) was 73%. All eight deaths in the series were related to aneurysm. CONCLUSION: Endovascular treatment of infective aortic pathology provides an early survival benefit; however, concerns over on-going graft infection remain.

Gaining consent for carotid surgery: a simulation-based study of vascular surgeons.

AIM: Despite no formal training in consenting patients, surgeons are assumed to be competent if they are able to perform an operation. We tested this assumption for carotid endarterectomy (CEA). METHODS: Thirty-two surgeons [Group 1: junior surgical trainees--performed 0 CEA's (n=11); 2: senior vascular trainees--1-50 CEA's (n=11); 3: consultant vascular surgeons - > 50 CEA's (n=10)] consented two patients (trained actors) for a local anaesthetic CEA. The performance was assessed at post hoc video review by two independent assessors using a validated rating scale and checklist of risk factors. RESULTS: There was no difference in performance between the junior and senior trainees (1: median 91 range 64-121; 2: median 100.5 range 66-125; p=0.118 1 vs. 2 Mann-Whitney). There was a significant improvement between senior trainees and consultant surgeons (3: median 120 range 89-1 142; p=0.001 2 vs. 3). Few junior (1/11) and senior (2/11) trainees, and most (8/11) consultants, were competent. Inter-rater reliability was high (alpha=0.832). Consultant surgeons were significantly more likely to discuss cranial nerve injuries (p<0.0001 Chi-square test) as well as personal or hospital specific stroke risk (p<0.0001) than their junior counterparts. They were less likely to discuss infection (p<0.0001). CONCLUSION: Senior trainees, despite being able to perform a CEA, were not competent in consent. The majority of consultant surgeons had developed competence in consenting even though they had no formal training.

Self-assessment of technical skill in surgery: the need for expert feedback.

INTRODUCTION: Technical skill has been formally assessed in the Fellow of the European Board of Vascular Surgery Examinations (FEBVS) since 2002. The aim of this study was to examine the relationship between expert assessment and trainee self-assessment. MATERIALS AND METHODS: Forty-two examination candidates performed a saphenofemoral junction (SFJ) ligation and an anterior tibial anastomosis on a synthetic simulation. Each candidate was rated by two examiners using a validated rating scale for their generic surgical skill for both procedures. Candidates then anonymously rated their own performance using the same scale. Parametric tests were used in the statistical analysis; a P-value < 0.05 was considered significant. RESULTS: The maximum mark in each assessment was 40; 24 was considered a competent score. The interobserver correlation for examiners marks were high (SFJ ligation, alpha = 0.68; distal anastomosis, alpha = 0.76). Examiners' marks were averaged. The mean examiner score for the SFJ ligation station was 27.8 (SD = 4.1) with 36 candidates (85.8%) attaining a competent score. The mean self-assessment score for this station was 30.7 (SD = 4.66). The mean examiners' marks for the distal anastomosis station was 29.2 (SD = 4.2); 39 candidates (92.8%) attained a competent score. The mean self-assessment score was 32.1 (SD = 4.0). There was no correlation between examiner and self-assessment scores in either station (Pearson's correlation coefficient: SFJ, r = 0.045, P = NS); distal anastomosis, r = 0.089, P = NS). Bland and Altman plots assessed the agreement between examiner and self-assessment. These showed candidates marked themselves higher than examiners with a mean difference of 2.9 marks in each station. CONCLUSIONS: Candidates' self-assessment and expert independent assessment correlate poorly. Trainees overestimate their ability according to independent assessment; regular technical feedback during training is, therefore, essential.

Thorascopic sympathectomy performed using laser.

INTRODUCTION: Thorascopic sympathectomy is accepted as an effective treatment for palmar hyperhidrosis, facial blushing and to a lesser extent for digital ischaemia and axillary hyperhidrosis. PATIENTS AND METHODS: Data were collected retrospectively on patients undergoing thorascopic sympathectomy at St Peter's Hospital between 1987 and 2006. Patients were followed up by telephone interview. RESULTS: A total of 233 thorascopic sympathectomy procedures were performed by a single operator in 123 patients. Ages ranged from 9-71 years and 75 were women. In patients, 105 had a bilateral and 13 a unilateral procedure, 5 patients had a bilateral procedure performed in two stages. In 6 upper limbs, the procedure could not be done. Overall, 110 patients (90%) had the procedure performed for palmar hyperhidrosis, 8 (6%) for facial blushing and in 5 (4%) patients the operation was performed for digital ischaemia with tissue loss. There were no deaths and all patients were discharged on day 1 following the procedure. Complications included bleeding (2), pulmonary oedema (1) and failed procedure (2); however, no incidences of Horner's syndrome occurred. Only 40 of 123 (32.5%) patients gave follow-up information. Of this small group, 33 of 40 (83%) were cured, 4 of 40 (10%) were better, 2 of 40 (5%) were unchanged and 1 patient was worse. Only 22 out of 40 (55%) of these patients were troubled by compensatory sweating, with only 4 of 40 (10%) reporting this as a major problem. CONCLUSIONS: Thorascopic sympathectomy is safe and can be carried out as a single bilateral procedure in the majority of cases. The laser allows the use of a single port, requires less dissection than surgical or clipping techniques, is more precise than diathermy and may be less likely to cause a Horner's syndrome.

Perioperative complications in patients with drug-eluting stents: a three-year audit at Geelong Hospital.

Drug-eluting stents are a recommended treatment for lesions in the coronary arteries. Stent insertion requires the patient remain on anti-platelet medication for a minimum of six months after insertion. A serious consequence of ceasing anti-platelet medication is late stent thrombosis leading to myocardial infarction in the territory of the drug-eluting stent. Continuing anti-platelet medication can lead to excessive bleeding at the time of surgery. Understanding the risk of complications attributable to bleeding or myocardial ischaemia will help in defining the optimal management of these patients at the time of non-cardiac surgery. This study is a retrospective database analysis and case note review of all patients with drug-eluting stents presenting for non-cardiac surgical procedures over a three-year period in one centre. Twenty-four patients with drug-eluting stents inserted presented for 43 non-cardiac surgical procedures. Severe bleeding problems were encountered in one case. Three of 15 patients (20%) who ceased clopidogrel prior to surgery without alternative anti-thrombotic prophylaxis suffered myocardial infarction due to stent thrombosis. Four patients who received alternative anti-thrombotic prophylaxis did not suffer complications. All 19 patients who ceased clopidogrel remained on aspirin prior to surgery. Patients treated with drug-eluting stents for coronary artery stenosis represent a challenging group of patients for subsequent perioperative management. The risk of myocardial infarction when clopidogrel is stopped prior to surgery is 20%, if alternative anti-thrombotic prophylaxis is not used. This risk persists beyond one year after insertion of drug-eluting stents. Some treatments appear to be effective in reducing the risk of myocardial infarction.

Competence assessment of senior vascular trainees using a carotid endarterectomy bench model.

BACKGROUND: Competency-based assessment is being introduced to surgical training. The value of bench-top technical skills assessment using a synthetic carotid endarterectomy (CEA) model was evaluated in vascular trainees and consultants. METHODS: Forty-one surgeons (13 junior trainees, 15 senior trainees and 13 experienced consultants with experience of more than 50 CEAs) performed a three-throw knot-tying exercise on a jig and a CEA on the bench model. A composite score for knot-tying was calculated, incorporating electromagnetic motion analysis. CEA technical skill was assessed using validated rating scales by blinded video analysis. RESULTS: Senior trainees performed better than junior trainees in knot-tying (P = 0.025) as well as generic (P < 0.001) and procedural (P < 0.001) skills on CEA model assessment. There was no difference between senior trainees and consultants on any of these measures. The CEA model interobserver reliability was high for all rating scales (generic alpha = 0.974, procedural alpha = 0.952, end-product alpha = 0.976). CONCLUSION: Senior trainees achieved the same score as consultants, suggesting a similar level of basic technical skill and knowledge required to perform CEA, and were significantly better than junior trainees. Performance on the bench model could provide an early assessment for suitability to proceed to operative training in a competency-based training and assessment programme.

Training for carotid intervention: preparing the next generation.

BACKGROUND: Carotid interventions are performed to reduce the cumulative risk of stroke. The success of the procedure is dependent upon maintaining low operative risk. This article reviews the current state of training for both carotid endarterectomy (CEA) and carotid angioplasty and stenting (CAS). METHODS: Medline searches were performed to identify articles with the combination of the following key words: carotid, endarterectomy, stent, training, assessment and simulation. Manual searches of the reference lists and related papers was conducted. RESULTS: Training and assessment for CEA and CAS follows the traditional apprenticeship model. There is no formal training protocol or objective means of assessment for either carotid endarterectomy or stenting. Models and simulators to allow for training and assessment away from the operative theatre have been developed, and exist for both CEA and CAS. CONCLUSION: The technology exists to allow for both training and assessment of competency to take place in a controlled and objective environment for both CEA and CAS. The use of simulation needs to be robustly evaluated and assessed to both complement and augment existing training programs to ensure that the highest standards of care are maintained for treatment of carotid territory disease. Objective competency based training and assessment is no longer unattainable. Simulators augment this process and without them operative exposure is sporadic and crisis management infrequent.

Epithelial and connective tissue cell CTGF/CCN2 expression in gingival fibrosis.

Gingival overgrowth is a side effect of certain medications and occurs in non-drug-induced forms either as inherited (human gingival fibromatosis) or idiopathic gingival overgrowth. The most fibrotic drug-induced lesions develop in response to therapy with phenytoin; the least fibrotic lesions are caused by cyclosporin A; and intermediate fibrosis occurs in nifedipine-induced gingival overgrowth. Connective tissue growth factor (CTGF/CCN2) expression is positively related to the degree of fibrosis in these tissues. The present study has investigated the hypothesis that CTGF/CCN2 is expressed in human gingival fibromatosis tissues and contributes to this form of non-drug-induced gingival overgrowth. Histopathology/immunohistochemistry studies showed that human gingival fibromatosis lesions are highly fibrotic, similar to phenytoin-induced lesions. Connective tissue CTGF/CCN2 levels were equivalent to the expression in phenytoin-induced gingival overgrowth. The additional novel observation was made that CTGF/CCN2 is highly expressed in the epithelium of fibrotic gingival tissues. This finding was confirmed by in situ hybridization. Real-time polymerase chain reaction (PCR) analyses of RNA extracted from drug-induced gingival overgrowth tissues for CTGF/CCN2 were fully consistent with these findings. Finally, normal primary gingival epithelial cell cultures were analysed for basal and transforming growth factor beta1 (TGF-beta1) or lysophosphatidic acid-stimulated CTGF/CCN2 expression at protein and RNA levels. These data indicate that fibrotic human gingival tissues express CTGF/CCN2 in both the epithelium and connective tissues; that cultured gingival epithelial cells express CTGF/CCN2; and that lysophosphatidic acid further stimulates CTGF/CCN2 expression. These findings suggest that interactions between epithelial and connective tissues could contribute to gingival fibrosis.

Assessing the impact of renal impairment on outcome after arterial intervention: a prospective review of 1,559 patients.

AIM: To investigate the impact of pre and peri-operative renal impairment on outcome, and the need for renal replacement therapy, in a multicenter study of patients undergoing a variety of surgical and radiological arterial procedures. METHODS: A six month prospective multi-centre study of 1,559 consecutive patients undergoing arterial interventions was performed. The primary outcome measures were the development of renal impairment, 30 day mortality and the need for renal replacement therapy. CRI was defined as an admission serum Creatinine>125 micromol/l. ARI was defined as a rise in serum Creatinine of >50% above pre-operative levels, excluding patients in whom the post operative level remained <125 micromol/l. A multivariate logistic regression model was constructed to identify independent risk factors for the development of ARI and mortality. RESULTS: There was a significantly increased 30 day mortality in those patients who developed ARI (29/90 - 32%) or who had CRI (43/269 - 16%) when compared with those whose creatinine remained normal throughout (44/1200 - 4%) (p<0.0001 - Chi-square test). One thousand two hundred and ninety patients had normal pre operative renal function and 269 patients had CRI. Seven percent (90/1290) of the patients with normal pre-operative creatinine developed ARI. Operation type, emergency presentation, and chronic renal impairment were independent predictors of both acute renal impairment (p<0.01) and mortality (p<0.001). Sixteen patients (1%) required temporary haemofiltration (in 9 patients this developed in the context of multiple organ failure) with only 1 requiring long term support. Eleven of these patients died (30 day mortality 69%). CONCLUSIONS: Renal failure following arterial intervention is associated with significant mortality. Renal replacement therapy is necessary mainly in the setting of multiple organ failure on intensive care units with few patients surviving to require long term renal replacement therapy. The identification of the 'at risk' patient is most strongly associated with age, raised preoperative creatinine, emergency procedures and thoraco-abdominal aneurysm.

Virtual reality simulation training can improve inexperienced surgeons' endovascular skills.

PURPOSE: The aim of this study was to evaluate virtual reality (VR) simulation for endovascular training of surgeons inexperienced in this technique. METHODS: Twenty consultant vascular surgeons were divided into those who had performed >50 endovascular procedures (e.g. aortic and carotid stent) as primary operator (n=8), and those having performed <10 procedures (n=12). To test for endovascular skill rather than procedural knowledge, all subjects performed a renal artery balloon angioplasty and stent procedure. The simulator uses real tools with active force feedback, and provides a realistic image of the virtual patient. Surgeons with endovascular skills performed two repetitions and those without completed six repetitions of the same task. The simulator recorded time taken for the procedure, the amount of contrast fluid used and total fluoroscopy time. RESULTS: Initially, surgeons with endovascular skills were significantly faster (median 571.5 vs. 900.0 s, p=0.039) and used less contrast fluid (19.1 vs. 42.9 ml, p=0.047) than inexperienced operators, though differences for fluoroscopy time were not significant (273 vs. 441 s, p=0.305). Over the six sessions, the inexperienced group made significant improvements in performance for time taken (p=0.007) and contrast fluid usage (p=0.021), achieving similar scores at the end of the training program to the experienced group. CONCLUSIONS: Surgeons with minimal endovascular experience can improve their time taken and contrast usage during short-phase training on a VR endovascular task. VR simulation may be useful for the early part of the learning curve for surgeons who wish to expand their endovascular interests.

Do workshops improved the technical skill of vascular surgical trainees?

AIMS: Adjuncts to conventional surgical training are needed in order to address the reduction in working hours. This purpose of this study was to objectively assess the efficacy of workshop training on simulators. METHODS: Fifteen consecutive participants of the European Vascular Workshop in 2003 and 2004 were recruited to this study. Participants performed a proximal anastomosis on a commercially available abdominal aortic aneurysm simulator, were then given intensive training on sophisticated models for 3 days and re-assessed. Pre- and post-course procedures were videotaped and independently reviewed by three assessors (tapes were blinded and in random order). The operative end product was similarly assessed. Four measures of technical skill were used: generic skill, procedural skill; a five point technical rating of the anastomosis (assessed using validated rating scales) and procedure time. Non-parametric tests were used in the statistical analysis. RESULTS: The video assessment scores for aneurysm repair increased significantly following completion of the course (p=0.006 and p=0.004 for generic and procedural skill, respectively). End product assessment scores increased significantly post-course (p=0.001) and participants performed aneurysm repair faster following the course (p<0.05). Inter-observer reliability ranged from alpha=0.84-0.98 for the three rating scales pre- and post-course. CONCLUSION: Objective improvements in technical performance follow intensive workshop training. Participants' perform better, faster, and with an improved end product following the course. Such adjuncts to training play an important part in a focused integrated programme that addresses reduced work hours.