A simulator for training in endovascular aneurysm repair: The use of three dimensional printers.

OBJECTIVES: To develop an endovascular aneurysm repair (EVAR) simulation system using three dimensional (3D) printed aneurysms, and to evaluate the impact of patient specific training prior to EVAR on the surgical performance of vascular surgery residents in a university hospital in Brazil. METHODS: This was a prospective, controlled, single centre study. During 2015, the aneurysms of patients undergoing elective EVAR at São Paulo University Medical School were 3D printed and used in training sessions with vascular surgery residents. The 3D printers Stratasys-Connex 350, Formlabs-Form1+, and Makerbot were tested. Ten residents were enrolled in the control group (five residents and 30 patients in 2014) or the training group (five residents and 25 patients in 2015). The control group performed the surgery under the supervision of a senior vascular surgeon (routine procedure, without simulator training). The training group practised the surgery in a patient specific simulator prior to the routine procedure. Objective parameters were analysed, and a subjective questionnaire addressing training utility and realism was answered. RESULTS: Patient specific training reduced fluoroscopy time by 30% (mean 48 min, 95% confidence interval [CI] 40-58 vs. 33 min, 95% CI 26-42 [p < .01]), total procedure time by 29% (mean 292 min [95% CI 235-336] vs. 207 [95% CI 173-247]; p < .01), and volume of contrast used by 25% (mean 87 mL [95% CI 73-103] vs. 65 mL [95% CI 52-81]; p = .02). The residents considered the training useful and realistic, and reported that it increased their self confidence. The 3D printers Form1+ (using flexible resin) and Makerbot (using silicone) provided the best performance based on simulator quality and cost. CONCLUSION: An EVAR simulation system using 3D printed aneurysms was feasible. The best results were obtained with the 3D printers Form1+ (using flexible resin) and Makerbot (using silicone). Patient specific training prior to EVAR at a university hospital in Brazil improved residents' surgical performance (based on fluoroscopy time, surgery time, and volume of contrast used) and increased their self confidence.

Impact of endovascular technique in vascular surgery training at a large university hospital in Brazil.

OBJECTIVES: The aim of this study was to determine the impact of endovascular surgery versus open vascular technique training in a Brazilian teaching service. DESIGN: Cross-sectional study. SETTING: Hospital das Clinicas-Faculty of Medicine-University of Sao Paulo, a tertiary institutional hospital-Brazil. PARTICIPANTS: We reviewed 1,040 arterial operations performed during 2 distinct time periods: January 1995 to December 1996, and January 2006 to December 2007. Based on the disease treated, the procedures were classified into the following 5 groups: abdominal aortic aneurysms (AAA), aorto-iliac obstructive disease (AI), obstructive disease of the femoropopliteal-tibial segment (FP), carotid disease (C), and others (O). The operations were also divided into an endovascular surgery (ES) group and an open surgery (OS) group. We compared the number of open and endovascular procedures for each arterial disease group during both periods. RESULTS: During the 2006-2007 period, 654 patients were treated surgically, whereas over the 1995-1996 period, 386 arterial operations were performed. A significant increase in endovascular procedures (p < 0.001) was found from the 1995-1996 period to the 2006-2007 period (35 vs 351, respectively) in all groups, whereas open surgery showed a slight increase in the number of procedures in the AAA and O groups only. In the 1995-1996 period, OS was the primary surgical method for all groups, but in the 2006-2007 time frame, OS was performed more frequently than ES only in the AAA and O groups. Considering all vascular disease groups, OS was the technique used in 90.9% (351 of 386) of the operations during 1995-1996, whereas in 2006-2007, OS was performed in only 46.3% (303 of 654) of the procedures. CONCLUSIONS: The increase in the number of ES observed over the past decade has had little impact on OS procedures performed at our medical center, not bringing harm to open surgical training.

Importance of exchange of vascular trainees among centers.

Training in surgery has for a long time been based on the classical model of master-apprentice, leading to the creation of "schools" comparable to the famous painter schools of Rubens, Rembrandt and many others during the Middle Ages. Although it may offer some advantages, this model is no longer suitable today. Modern vascular surgery covers several fields, including not only open vascular and endovascular treatment, but also non-invasive diagnosis and medical treatment of vascular diseases in different parts of the human body. However, the goal of training remains the formation of a "holistic vascular surgeon", with knowledge of and experience in all these areas. As most training centers are more focused on and have more expertise in one or some of these areas, an ideal training curriculum would consist of a rotation between different centers with different points of attention and possibly even rotations in other specialties, such as interventional radiology, vascular medicine or ultrasonography. Such an exchange cannot only be beneficial for the trainee but contact with trainees with a different background can also offer an added value to the training center. Thanks to new ways of communication and transportation, exchange of trainees, even in different countries, has become much easier. Nevertheless, a problem often arises concerning the requirements for training as, despite the many efforts already undertaken, it still differs significantly between different countries. The development of a core-curriculum and mutual recognition of training centers is urgently needed and further steps in the harmonization of training programs and requirements need to be stimulated.