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Use of Virtual Reality Simulation for Mission Rehearsal for Carotid Stenting
To the Editor: Carotid stenting has been shown to be noninferior to carotid endarterectomy for treatment of severe carotid stenosis.1 Virtual reality simulation training to proficiency has been recommended in the certification process for carotid stenting.2-3 Virtual reality simulation also allows mission rehearsal,4 practicing a procedure using an individual patient's anatomy in a virtual environment prior to the actual procedure. Although this concept is used by the military and in aviation, we are not aware of prior implementation in medical practice. We describe what we believe to be the first mission rehearsal carotid stenting case using a specific patient's digital vascular anatomy.
Methods
The patient was a 64-year-old man with severe chronic obstructive pulmonary disease, prior right carotid endarterectomy, and recent transient ischemic attacks. The right internal carotid artery had an ulcerated lesion with 80% stenosis. After written and oral informed consent, the patient underwent virtual reality mission rehearsal of the carotid stenting, immediately followed by the same physician operator performing the actual procedure.
A vascular training simulator (Procedicus Vascular Interventional System Trainer, Mentice AB, Gothenburg, Sweden) was used for the procedure.5-6 Magnetic resonance angiogram images of the patient's aortic arch vessels and cerebral anatomy were converted into a standard Digital Imaging and Communications in Medicine (DICOM) format, loaded on the simulator, and used to recreate the patient's vascular anatomy in virtual reality.
Virtual Reality–Simulated Case. An arch aortogram was performed using a 6F pigtail catheter in the left anterior oblique view. A 6FRight4-Judkins coronary catheter through an 8F 80-cm multipurpose guide–catheter was used to engage the innominate artery. A guidewire cannulated the right common carotid artery, into which the Judkins catheter was advanced. Using a telescoping technique, the multipurpose guide was advanced over the Judkins catheter into the right common carotid artery. Selective angiograms through the multipurpose guide showed good visualization of the carotid lesion. The embolic protection device landing zone was identified. Based on the catheter-size to vessel-diameter ratio, a 6.5-mm embolic protection device was deployed. A 4-mm x 20-mm balloon was used to predilate the lesion. A tapered 6-mm to 8-mm x 30-mm stent was placed and deployed using a device that simulated the hand-specific movements for device deployment. The stented segment was postdilated using a 5-mm x 20-mm balloon. The postballoon angiogram showed an excellent result with residual stenosis of 0%. The embolic protection device was collapsed and retrieved.
Live Patient Case. The live case immediately followed. As with the virtual reality case, the guidewire initially selected the left subclavian in rounding the aortic arch. This required advancement of the pigtail catheter for redirecting into the ascending aortic arch. The sizes of balloons, stent, and embolic protection device were the same as those identified in the virtual reality case, with appropriate choice confirmed by angiography. Quantitative angiography analysis for appropriate sizing of devices was not required. A left anterior oblique arch aortogram demonstrated the same anatomy and identified the difficulty rounding the arch to the ascending aorta. A 6F 100-cm Judkins coronary catheter in an 8F 80-cm multipurpose guide engaged the innominate artery, and the telescoping technique was used. Angiograms using the same camera angles showed the lesion and landing zone site of the embolic protective device. The postballoon angiogram showed resolution of the ulceration and residual stenosis of 0%. The embolic protective device was collapsed and retrieved.
Results
Virtual reality–simulated and live-patient cases showed a high degree of similarity of the angiographic anatomy (Figure). All catheter movement and handling dynamics, catheter-catheter interaction, wire movement and dynamics, and embolic protective device deployment and retrieval demonstrated a one-to-one correlation of device movement in virtual reality compared with the live-patient case. Decisions about catheter selection (correct sizing of balloon, embolic protective device, and stent) and catheter technique (catheter- and wire-handling dynamics) transferred directly and correlated with the live-patient procedure. The rehearsal allowed the operator to anticipate and prepare for the approach to aortic arch access and choose the devices without the added time requirement of online quantitative angiography analysis. The patient had no complications in the hospital and was asymptomatic at the 1-year follow-up visit.
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Figure. Comparison of Simulated and Actual Case Angiograms of the Aortic Arch and Right Common Carotid Artery
Arrowheads indicate carotid artery lesion in the lateral view of the simulated and actual right common carotid artery.
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Comment
This case shows that mission rehearsal in humans can be performed with currently available virtual reality–simulation technology, that decisions made during the rehearsal may directly translate to the actual patient, and that operators can practice with the patient's own anatomy without risk. By identifying optimal patient-specific techniques prior to the actual procedure and promoting proficiency,5 virtual reality simulation has the potential for improved patient safety.
Access to Data: Dr Cates had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Financial Disclosures: None reported.
Funding/Support: None.
Acknowledgment: The patient described in this article provided permission for his clinical information and images to be included.
Christopher U. Cates, MD
christopher.cates{at}emoryhealthcare.org
Amar D. Patel, MD;
William J. Nicholson, MD
Division of Cardiology
Department of Medicine
Emory University School of Medicine
Atlanta, Ga
1. Yadav JS, Wholey MH, Kuntz RE, et al. Protected carotid-artery stenting versus endarterectomy in high-risk patients. N Engl J Med. 2004;351:1493-1501.
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2. Gallagher AG, Cates CU. Approval of virtual reality training for carotid stenting: what this means for procedural-based medicine. JAMA. 2004;292:3024-3026.
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3. Rosenfield K, Babb JD, Cates CU, et al. Clinical competence statement on carotid stenting. J Am Coll Cardiol. 2005;45:165-174.
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4. Gallagher AG, Cates CU. Virtual reality training for the operating room and cardiac catheterization laboratory. Lancet. 2004;364:1538-1540.
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5. Patel AD, Gallagher AG, Nicholson WJ, Cates CU. Learning curves and reliability measures for virtual reality simulation in the performance assessment of carotid angiography. J Am Coll Cardiol. 2006;47:1796-1802.
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6. Nicholson WJ, Cates CU, Patel AD, et al. Face and content validation of virtual reality simulation for carotid angiography [simulation in Healthcare]. J Soc Med Simul Healthcare. 2006;1:147-150.
Letters Section Editor: Robert M. Golub, MD, Senior Editor.
JAMA. 2007;297:265-266.
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