Objective Assessment of Endovascular Navigation Skills with Force Sensing.

Despite the increasing popularity of endovascular intervention in clinical practice, there remains a lack of objective and quantitative metrics for skill evaluation of endovascular techniques. Data relating to the forces exerted during endovascular procedures and the behavioral patterns of endovascular clinicians is currently limited. This research proposes two platforms for measuring tool forces applied by operators and contact forces resulting from catheter-tissue interactions, as a means of providing accurate, objective metrics of operator skill within a realistic simulation environment.

Reducing contact forces in the arch and supra-aortic vessels using the Magellan robot.

Objective: Conventional catheter manipulation in the arch and supra-aortic trunks carries a risk of cerebral embolization. This study proposes a platform for detailed quantitative analysis of contact forces (CF) exerted on the vasculature, in order to investigate the potential advantages of robotic navigation.

Methods: An anthropomorphic phantom representing a type I bovine arch was mounted and coupled onto a force/torque sensor.

Virtual reality simulation for the optimization of endovascular procedures: current perspectives.

Endovascular technologies are rapidly evolving, often requiring coordination and cooperation between clinicians and technicians from diverse specialties. These multidisciplinary interactions lead to challenges that are reflected in the high rate of errors occurring during endovascular procedures. Endovascular virtual reality (VR) simulation has evolved from simple benchtop devices to full physic simulators with advanced haptics and dynamic imaging and physiological controls.

Endovascular repair of ruptured abdominal aortic aneurysm: technical and team training in an immersive virtual reality environment.

Purpose: This study evaluates a fully immersive simulated angiosuite for training and assessment of technical endovascular and human factor skills during a crisis scenario.

Materials And Methods: Virtual reality (VIST-C, Mentice) simulators were integrated into a simulated angiosuite (ORCAMP, Orzone). Teams, lead by experienced (N = 5) or trainee (N = 5) endovascular specialists, performed simulated endovascular ruptured aortic aneurysm repair (rEVAR).

Salmonella mycotic thoracoabdominal aortic aneurysm associated with chronic lymphocytic leukemia.

Non-typhoidal Salmonella infections typically cause self-limiting gastroenteritis. However, extraintestinal focal infections, including mycotic aneurysms of the aorta, can also occur. We present the case of a 71-year-old man with chronic lymphocytic leukemia (CLL) and a large type V thoracoabdominal mycotic aneurysm infected with Salmonella enteritidis, complicated by thoracolumbar spondylodiscitis, paravertebral collections, and epidural abscess.

In vitro fenestration of aortic stent-grafts: implications of puncture methods for in situ fenestration durability.

Purpose: To investigate the quality of stent-graft fenestrations created in vitro using different needle puncture and balloon dilation angles in different commercial endografts.

Methods: Fenestrations were made in a standardized fashion in 3 different endograft types: Talent monofilament twill woven polyester, Zenith multifilament tubular woven polyester, and Endofit thin-walled expanded polytetrafluoroethylene (PTFE). Punctures were made at 30°, 60°, and 90° angles using a 20-G needle and dilated using 6-mm standard and 7-mm cutting balloons; at least 6 fenestrations were made at each angle with standard balloons and at least 6 with cutting balloons.

Initial findings and potential applicability of computational simulation of the aorta in acute type B dissection.

Objective: Type B aortic dissection can be acutely complicated by rapid expansion, rupture, and malperfusion syndromes. Short-term adverse outcomes are associated with failure of the false lumen to thrombose. The reasons behind false lumen patency are poorly understood, and the objective of this pilot study was to use computational fluid dynamics reconstructions of aortic dissection cases to analyze the effect of aortic and primary tear morphology on flow characteristics and clinical outcomes in patients with acute type B dissections.

Renal artery aneurysm formation secondary to pseudoxanthoma elasticum.

This report describes a patient with pseudoxanthoma elasticum (PXE) who presented with an incidental finding of a renal artery aneurysm. PXE is a rare genetic condition. It is associated with calcification of elastin fibers and is characterized by skin, eye, and cardiovascular complications.

Reducing errors in combined open/endovascular arterial procedures: influence of a structured mental rehearsal before the endovascular phase.

Purpose: To assess the incidence of errors before and after implementation of a structured mental rehearsal prior to the endovascular phase of combined open/endovascular arterial procedures.

Methods: Over 6 weeks, 15 combined open/endovascular procedures (7 abdominal aorta and 8 thoracic aorta) lasting 58 hours were evaluated by a trained observer. In a blinded fashion, 2 individuals scrutinized event logs for errors, which were categorized by type, by potential to cause patient harm (danger), and by potential to disrupt the procedure (delay).

Reducing error and improving efficiency during vascular interventional radiology: implementation of a preprocedural team rehearsal.

Purpose: To determine the type and frequency of errors during vascular interventional radiology (VIR) and design and implement an intervention to reduce error and improve efficiency in this setting.

Materials And Methods: Ethical guidance was sought from the Research Services Department at Imperial College London. Informed consent was not obtained.

Lower-limb ischemia in the young patient: management strategies in an endovascular era.

Background: The aim of this paper is to review the potential role of endovascular interventions for young patients with lower-limb ischaemia.

Methods: A literature search was performed of PubMed and Medline databases using appropriate search terms and limits. Case reports, retrospective studies, and prospective studies evaluating treatment of lower-limb ischemia in patients aged <50 years were scrutinized.

Evaluation of robotic endovascular catheters for arch vessel cannulation.

Objective: Conventional catheter instability and embolization risk limits the adoption of endovascular therapy in patients with challenging arch anatomy. This study investigated whether arch vessel cannulation can be enhanced by a remotely steerable robotic catheter system.

Methods: Seventeen clinicians with varying endovascular experience cannulated all arch vessels within two computed tomography-reconstructed pulsatile flow phantoms (bovine type I and type III aortic arches), under fluoroscopic guidance, using conventional and robotic techniques.

In situ fenestrations for the aortic arch and visceral segment: advances and challenges.

The management of complex aortic pathologies remains a major challenge particularly in the emergency setting. Bespoke fenestrated and branch stent graft technology has shown encouraging short- and mid-term results in selected patients. Despite tremendous technological advances in this field however, factors such as the inherent delay in device manufacturing, anatomical and technical challenges, high degree of planning, and cost hinder the wider applications of minimally invasive endovascular therapy.

The changing management of primary mycotic aortic aneurysms.

Objective: The objective of this study is to examine contemporary management of primary mycotic aortic aneurysms in a single center. We have previously reported the management of mycotic aortic aneurysms in 15 patients between 1991 and 2001, and we hypothesized that management would change in the light of the evolution of endovascular aortic repair.

Methods: A review of a prospectively collected database (2002-2009) of all patients presenting with mycotic aneurysms.

Scalloped thoracic stent-graft for treatment of aortic arch aneurysms with unfavourable landing zones.

Endovascular treatments are limited in cases of thoracic aortic aneurysms extending up or proximal to the origin of the left subclavian artery (LSCA). In such cases, the LSCA is usually either occluded or revascularised. We report our first experience of four patients who underwent thoracic aneursym treatment with new custom-made grafts with a scallop in situ for the LSCA.

Hybrid and endovascular therapy for extensive thoracoabdominal aortic disease.

The past 4 decades have witnessed tremendous strides in the evolution of endovascular technology with increased operator experience, greater availability of more sophisticated and versatile endovascular devices, and advances in imaging modalities. In an attempt to limit the physiologic derangements associated with aortic crossclamping and extensive tissue dissection during traditional open surgical repair of extensive thoracoabdominal aortic aneurysms, less invasive strategies have been explored using endovascular technology: hybrid approaches and solely endovascular techniques. This article describes these techniques and their advantages, their current role in thoracoabdominal aortic aneurysm repair and potential future developments in this field.

Skills training after night shift work enables acquisition of endovascular technical skills on a virtual reality simulator.

Background: Adoption of residents' working time restrictions potentially undermines surgical training by reduction of operating room exposure. Simulation has been proposed as a way to acquire necessary skills in a laboratory environment but remains difficult to incorporate into training schedules. This study assessed whether residents working successive nights could acquire endovascular skills similar to colleagues working day shifts.

Clinical applications of robotic technology in vascular and endovascular surgery.

Background: Emerging robotic technologies are increasingly being used by surgical disciplines to facilitate and improve performance of minimally invasive surgery. Robot-assisted intervention has recently been introduced into the field of vascular surgery to potentially enhance laparoscopic vascular and endovascular capabilities. The objective of this study was to review the current status of clinical robotic applications in vascular surgery.

Visuospatial and psychomotor aptitude predicts endovascular performance of inexperienced individuals on a virtual reality simulator.

Objectives: This study evaluated virtual reality (VR) simulation for endovascular training of medical students to determine whether innate perceptual, visuospatial, and psychomotor aptitude (VSA) can predict initial and plateau phase of technical endovascular skills acquisition.

Methods: Twenty medical students received didactic and endovascular training on a commercially available VR simulator. Each student treated a series of 10 identical noncomplex renal artery stenoses endovascularly.

The role of robotic endovascular catheters in fenestrated stent grafting.

Objective: Fenestrated stent grafting has allowed the treatment of complex thoraco-abdominal aneurysm disease via a totally endovascular approach, but the procedure can be technically challenging and time consuming. We investigated whether this procedure may be enhanced by remotely steerable robotic endovascular catheters.

Methods: A four-vessel fenestrated stent graft partially deployed within a computed tomography (CT)-reconstructed pulsatile thoraco-abdominal aneurysm silicon model was used.

Combined sterno-clavicular approach as an alternative technique in hybrid exclusion of aortic arch aneurysm.

Background: We describe a modified access technique for the proximal (open) part of single stage hybrid exclusion of aneurysm of the aortic arch.

Case Presentation: 3 patients had a bifurcated Dacron graft for the innominate and left subclavian arteries and an additional end-to-side anastomosis of the left common carotid artery on the limb to the left subclavian artery. With our modification, access to the left subclavian artery is by left subclavicular incision and creation of an anterior tunnel via the left thoracic outlet from the origin of the left subclavian artery along its anatomical course to the subclavicular plane.

Complex thoracoabdominal aortic aneurysms: endovascular exclusion with visceral revascularization.

Objective: We review our ongoing experience with a transabdominal stent repair of complex thoracoabdominal aneurysms (Crawford type I, II, and III) with surgical revascularization of visceral and renal arteries.

Methods: A retrospective review was conducted of prospectively collected data from 29 consecutive patients who underwent an attempted visceral hybrid procedure between January 2002 and April 2005. Twenty-two patients were elective, four were urgent (symptomatic), and three were emergent (true rupture).

Splenic malformation in a patient with Klippel-Trenaunay syndrome: a case report.

A 22-year-old woman with a diagnosis of Klippel-Trenaunay syndrome presented with pain in the left hypochondrium and vomiting. Investigations revealed a huge splenomegaly with multiple hypodense lesions and irregular, linearly enhanced areas. She underwent splenectomy and had good postoperative recovery.

The Giacomini vein as an autologous conduit in infrainguinal arterial reconstruction.

The standard conduit in infrainguinal arterial bypass grafting, the great saphenous vein, is often unavailable. Arm and small saphenous veins are used as alternative conduits; yet both are deficient in length to accommodate femorocrural bypasses as a single conduit. In light of its high prevalence, the Giacomini vein harvested in continuity with the small saphenous vein may offer the latter extra length, promoting their combination into a single conduit able to meet the needs of infrainguinal reconstruction, particularly in lengthy infrainguinal bypass grafting.

Three-dimensional reconstruction of autologous vein bypass graft distal anastomoses imaged with magnetic resonance: clinical and research applications.

High-resolution magnetic resonance imaging was combined with computational modeling to create focused three-dimensional reconstructions of the distal anastomotic region of autologous vein peripheral bypass grafts in a preliminary series of patients. Readily viewed on a personal computer or printed as hard copies, a detailed appreciation of in vivo postoperative features of the anastomosis is possible. These reconstructions are suitable for analysis of geometric features, including vessel caliber, tortuosity, anastomotic angles, and planarity.