Vascular surgery is a low-volume/high complexity specialty, where rigorous training and assessment of technical skills is vital. Therefore, traditional apprenticeship model may not be valid in the modern practice. Besides that, during the COVID-19 pandemic, there was concern among surgical educators that residents are unprepared to independently practice the full spectrum of vascular surgery; since an important reduction in the number of surgeries was expected. This study aimed to assess skill acquisition and operative competency of the vascular surgery residents analyzing their performance on iliac and infra-inguinal angioplasties on a virtual reality simulator.

This was a prospective, controlled, single centered study. During three consecutive year (2018-2020), the residents in their final year of vascular residency at Hospital das Clínicas FMUSP were enrolled in this study. The residents of 2018 (Control Group) performed their residency according to the routine of our institution, which is mainly traditional apprenticeship model, and their surgical performance on iliac and infra-inguinal angioplasty was evaluated at the end of their residency using Angiomentor (Simbionix Ltd, Israel). During the two consecutive years, the residents were trained with Angiomentor in two workshops: at the beginning and at the middle of the final year of their residency. The residents and fellow from 2019 were the Training Group and the residents and fellow from 2020 were COVID Group, since their training occurred during the first pandemic year of COVID-19 in Brazil. The residents were evaluated using Objective Structured Assessment of Technical Skills (OSATS), and objective measures made by Angiomentor at the beginning, middle and end of their final year of vascular surgery residency (Figure 1). Their progression was recorded, and their final results were compared to the Control Group. The iliac and infra-inguinal angioplasties performed by the residents was calculated. Data were subjected to statistical analysis, and p<0.05 was considered significant, results are shown in Mean and Standard Deviation (SD) or Median and Interquartile Range (IQR).

The groups consisted of five residents and were similar analyzing residents' age (Control Group median 31 IQR 1, Training Group 30 IQR 1.5, COVID Group median 29.5 IQR 2.48, p=0.55 Kruskall-Wallis test) and sex (Control Group 40% female sex, Training Group 50%, COVID Group 66.7%, p=0.83 Fisher Exact test). The residents from COVID group performed the same numbers of limb angioplasties comparing with the two previous years: mean number of iliac angioplasties (Control 5.4 SD 1.82, Training Group 5 SD3.03 vs COVID Group 6.16 SD2.93; p=0.75 Anova test) and mean number of infra-inguinal angioplasties (Control 19 SD 5.13 vs Training 18.17 SD 5.84, COVID 18.33 SD 6.44; p= 0.91 Anova test). Analyzing OSATS, residents from Training and COVID groups showed a significant improvement after the workshops (Figure 2). At the end of PGY-4, residents from Training and COVID Groups scored better compared to residents who did not underwent simulator training in iliac (Median OSATS - Control Group 22 IQR 3, Training Group 32 IQR 2.25, COVID group 30.5 IQR 2.5; p= 0.006 Kruskall Wallis) and infra-inguinal angioplasties (Median OSATS - Control Group 21.5 IQR 2, Training 32.5 IQR 2.5, COVID 30.5 IQR7.1 vs, p= 0.004 Kruskall Wallis). Comparing surgery time, fluoroscopy time, residual stenosis and number of roadmaps there was no difference comparing the three groups. The residents of Training and COVID groups reported an improvement in their knowledge, technical skills and confidence after simulator training.

Training using a virtual reality simulator improved vascular surgery residents' surgical skills and their confidence in iliac and infra-inguinal angioplasty.