Abstract
Background
Remote tele-proctoring has been conducted in neuro-endovascular surgery, however, evidence to support its use in the fellowship training is limited. We demonstrate a novel augmented reality tele-proctoring platform to enable a remote attending to guide a fellow.
Methods
A consecutive series of neuro-endovascular cases were performed by a neuro-endovascular fellow with remote guidance from an attending surgeon. The fellow and attending were connected using a commercially available cloud-based platform designed to capture and stream up to four live video feeds from a clinical environment to a remote user. In this setting, two video streams were obtained directly from the anteroposterior and lateral cameras on the biplane. Additional video of the operator from a telescopic camera was streamed live to the remote attending surgeon. The attending could provide immediate vocal feedback and also deploy the platform's augmented reality tools to communicate with the fellow in the angiography suite.
Results
A total of 10 cases were performed on eight patients utilizing the cloud-based tele-proctoring platform to facilitate instruction. The series included diagnostic angiograms and interventions such as intracranial balloon angioplasty, carotid stenting, and intracranial stenting. All cases were a technical success. No complications or deaths occurred. When compared to similar cohort of 10 cases prior to these which utilized a traditional instruction paradigm; we saw no differences in contrast use (p = 0.38), fluoroscopy time (p = 0.85), or technical success.
Conclusions
This study demonstrates successful use of an augmented reality tele-proctoring platform to guide a neuro-endovascular fellow through complex neuro-interventional procedures from a remote setting.
Keywords: Telemedicine, fellowship, mentor
Introduction
Remote tele-proctoring has been used to instruct established neuro-interventionalists (ALG) in deploying new devices intraoperatively and has also been applied to virtual scenarios.1,2 However, evidence of its use to support residency and fellowship training is limited. We seek to demonstrate that instruction of complex neuro-interventional procedures can occur remotely, allowing an early-stage neuro-endovascular fellow to retain a high degree of autonomy while still being able to access real time guidance from an attending using a novel augmented reality tele-proctoring platform.
Methods
A consecutive series of 10 neuro-endovascular cases performed by a fellow utilizing the Proximie platform to seek remote support from an attending was queried from a prospectively maintained database (Table 1). Proximie is a commercially available developed original for use in the operating room. Additionally 10 cases immediately prior to arrival of the Proximie platform were retrospectively analyzed. The database is compiled at the comprehensive stroke center which has a process for data collection that has been approved by the Metrowest Medical Center Institutional Review Board (IRB) number 2019–149.
Table 1.
Baseline clinical and peri-operative imaging characteristics of patients in the tele-proctoring group.
| Case | Diagnosis | Procedure | Technical success | Immediate postoperative complications |
|---|---|---|---|---|
| 1 | Symptomatic vertebral artery dissection | Diagnostic 6 vessel cerebral angiogram | Yes | None |
| 2 | Carotid stenosis | Diagnostic 6 vessel cerebral angiogram | Yes | None |
| 3 | Symptomatic ICAD failed medical management | Left inferior division MCA balloon angioplasty | Yes | None |
| 4 | Symptomatic carotid web failed anticoagulation | Left CAS | Yes | None |
| 5 | Symptomatic carotid stenosis > 50% | Left CAS | Yes | None |
| 6 | Chronic MCA occlusion | Diagnostic 4 vessel angiogram | Yes | None |
| 7 | Symptomatic ICAD | Diagnostic 4 vessel angiogram | Yes | None |
| 8 | Carotid stenosis | Right CAS | Yes | None |
| 9 | Carotid stenosis | Diagnostic 4 vessel cerebral angiogram and Right CAS | Yes | None |
| 10 | Symptomatic vertebral artery dissection | Right V4 segment balloon angioplasty and Wingspan stent | Yes | None |
CAS: carotid artery stenting; ICAD: intracranial atherosclerotic disease; MCA: middle cerebral artery.
The cases in this series were all performed by a single neuro-endovascular fellow (SKD). All patients participating in this case series provided their consent for the procedure as well as for the technology to be used. An established neuro-interventionalist (ALG) also privileged at our facility was present in the control room during all cases and immediately available should the need arise. The attending of record (AEH or WGT) was situated in a remote location within the hospital and connected to the angiography suite through the Proximie platform. Proximie is a fully health insurance portability and accountability act and general data protection regulation compliant cloud-based solution that enables users to capture and stream up to four live video feeds from a clinical or operating room environment to a remote user using a laptop, capture card, and webcam. In this setting, two video streams were obtained directly from the biplane (anterioposterior and lateral views) and two additional views of the interventional suite were captured from cameras setup within the room. The supplementary cameras were angled to show the placement of the surgeon's hands and the preparation (scrub) table. All four videos were streamed live to the proctoring attending surgeon in order to provide situational awareness. The attending was able to remotely provide immediate vocal feedback to the fellow intraoperatively and deploy Proximie's augmented reality tools to provide precise visual guidance. In turn, the fellow was able to view the attending's illustrations in real time on a screen located in the operating room.
Results
A total of 10 consecutive cases were performed on eight patients during the study period utilizing Proximie platform (Table 1). The median age of participants was 63 ± 18.6 years. The 30% of the patients in the series were women. Fluoroscopy time averaged 20.5 ± 19.9min. Contrast use averaged 61 ± 23ccs. All cases were a technical success. No complications or deaths were recorded in the immediate postoperative period. The 10 consecutive cases performed prior to arrival of the tele-proctoring platform performed under a traditional paradigm of attending surgeon being present with the fellow were also reviewed (Table 2). Average fluoroscopy time averaged 22.1 ± 17.8 min. Average contrast use averaged 72.4 ± 32.8 ccs. We saw no differences between the two groups in terms of contrast use (p = 0.38), fluoroscopy time (p = 0.85), or rate of technical success.
Table 2.
Baseline clinical and peri-operative imaging characteristics of patients in the traditional teaching paradigm.
| Case | Diagnosis | Procedure | Technical success | Immediate postoperative complications |
|---|---|---|---|---|
| 1 | ICAD; right posterior cerebral artery stenosis | Diagnostic 6 vessel cerebral angiogram | Yes | None |
| 2 | ICAD; right posterior cerebral artery stenosis | Diagnostic 6 vessel cerebral angiogram | Yes | None |
| 3 | Subarachnoid hemorrhage; ruptured anterior communicating artery aneurysm | Balloon assisted coiling | Yes | None |
| 4 | Intracerebral hemorrhage | Diagnostic 6 vessel cerebral angiogram | Yes | None |
| 5 | Carotid stenosis follow up for prior carotid stent | Diagnostic 4 vessel cerebral angiogram | Yes | None |
| 6 | Recurrent right sided chronic subdural hematoma | Diagnostic 4 vessel angiogram and embolization of right sided middle meningeal artery | Yes | None |
| 7 | Acute ischemic stroke with large vessel occlusion of right MCA | Diagnostic 4 vessel angiogram; mechanical thrombectomy of proximal right MCA | Yes | None |
| 8 | Acute ischemic stroke | Diagnostic 4 vessel angiogram | Yes | None |
| 9 | Intracerebral hemorrhage | Diagnostic 6 vessel cerebral angiogram | Yes | None |
| 10 | Intracerebral hemorrhage | Diagnostic 6 vessel cerebral angiogram | Yes | None |
ICAD: intracranial atherosclerotic disease; MCA: middle cerebral artery.
Illustrative case
A patient presented to the emergency department with headaches and associated neck pain. Magnetic resonance imaging demonstrated an acute right lateral medullary infarct. The patient was referred to the neuro-endovascular service due to continued fluctuations in their neurological examination despite medical management for diagnostic cerebral angiography which demonstrated right sided dissection of the V4 segment (Figure 1). The patient was subsequently administered a loading dose of Plavix and underwent intracranial angioplasty with a gateway balloon and stenting with wingspan over the dissected segment of the vertebral artery performed independently by the fellow with guidance from an attending using the Proximie platform. After successful deployment of the stent, severe spasm of the V3 segment was appreciated by the attending over the live feed from the biplane. The attending instructed the fellow to administer a total of 15 mg of verapamil. A follow-up final run showed no significant residual stenosis or evidence of thrombus or spasm (Figure 1).
Figure 1.
The frame on the right demonstrates an intimal flap with more than 90% stenosis of the right V4 segment consistent with dissection seen on the initial diagnostic angiogram. The frame on the left shows the same segment treated after angioplasty with a Gateway balloon and deployment of a Wingspan stent.
Discussion
To our knowledge, this is the first real-world example utilizing tele-proctoring software with an augmented reality overlay to instruct a neuro-endovascular fellow in complex neuro-interventional procedures. Prior work has focused on proctoring established interventionalists in deploying new devices or instructing nonneuro interventionalists on a simulated model, such as Mentice1,2 or creating experiences such as the European society of minimally invasive neurological therapy e-fellowship which allow a select group of fellows to view but not perform the actual neuro-interventional procedures.
Based on feedback from the operating fellow, the attending's ability to provide precise guidance through live telestration was instrumental to the instruction process (Figure 2). Proximie's augmented reality tools facilitated the attending's ability to communicate effectively and provide instruction on key steps, such as how far to advance the distal access catheter, while allowing the fellow to physically perform the procedure autonomously. Additional Proximie features, such as the ability to stream four live camera feeds at once distinguishes the platform from other tele-mentoring systems and provides proctors with exceptional situational awareness. In this setting, the proctor was able to simultaneously view anteroposterior and lateral biplane images as well as the operating surgeon's hand and the preparation table, providing him with an immersive experience and ensuring that he was able to provide accurate guidance. Proctors were also able to zoom into the fellow's workspace to view images in detail and use a “virtual pointer hand” to denote specific structures (Figure 2).
Figure 2.
The top frame right demonstrates the desktop view of Proximie from the attending's office during deployment of distal embolic protection device for a carotid stenting procedure. The top frame left demonstrates the fellow's view of the laptop. The bottom frame demonstrates the annotations made by attending that could be seen by the fellow during an intracranial balloon angioplasty for severe symptomatic post M1 bifurcation stenosis.
Application of the platform also enabled the fellow to retain a high degree of self-perceived autonomy while facilitating the attending of record to engage to a higher degree than if he were physically present in the control room. While this feedback represents opinions of a single center, the authors believe that adoption of this technology within the graduate medical education space may help to solve the sometime contradictory mandates of trainee autonomy with close supervision.
Our experience can also be translated to help the lower volume centers safely accomplish complex neuro-endovascular interventions and continue mentorship of early career neuro-interventionalist after completion of fellowship training.3,4
Use of high-fidelity audiovisual communication to facilitate tele-mentoring between surgeons during a procedure, even within neurosurgery, is not new.5,6 Nonetheless adoption has remained limited, mainly due to cost, availability, and integration of technology within the theatre environment. Early systems like Socrates from Intuitive Surgical, for example, required bulky separate, dedicated workstations. 6 Proximie on the other hand is a hardware-agnostic, meaning it is compatible with existing hardware regardless of make or model. In our case, no modifications were physically made in angiography suite. A convertor was able to capture the digital output feed from anterioposterior and lateral cameras to transmit over Proximie. The advantage of this cannot be understated. Other contemporary tele-proctoring solutions involve using a high-definition camera to record a monitor which is problematic in scenarios where an internet service provider may be throttling a connection. As such, Proximie can be used in low bandwidth environments operating on any Wi-Fi, ethernet, or 3rd generation/4th generation/5th generation hot spot connection. This allows Proximie compatibility with mobile devices such as tablets and smart phones. Finally, sessions streamed using the platform can be recorded and securely stored in the Proximie library for review.
As demand at community level for neuroendovascular procedures such as mechanical thrombectomy increase across the world, we predict novel tele-proctoring platforms, such as Proximie, can successfully be implemented to support remote mentoring and supervision of surgeons and interventionalists in low- and middle-income countries to form the basis to true tele-fellowships in neuro-endovascular surgery.7,8
Limitations
The authors acknowledge several limitations to this study. Firstly, the study represents a single center experience where a high degree of personal rapport already existed between individuals within the practice group. The importance of this in facilitating virtual interactions via the tele-proctoring software cannot be understated. Secondly, many cases in this series were straightforward, such as carotid stenting or diagnostic angiography. Our experience will continue to evolve in respect to more complicated neurovascular cases.
Conclusion
The Proximie augmented reality platform was successfully deployed to supervise and instruct an early neuro-endovascular fellow through complex neuro-interventional procedures from a remote setting.
Footnotes
Author contributions: AEH formulated the research question, supervised the cases as described, revised the paper, and reviewed the final draft of the paper. SKD performed the clinical cases, analyzed the data, drafted the paper, and revised the paper. ALG supervised clinical cases as described, revised the paper, and reviewed the final draft of the paper. WGT supervised clinical cases as described, revised the paper, and reviewed the final draft of the paper.
Ethical approval: The study was approved by the Metrowest Medical Center IRB #2019-149.
Declaration of conflicting interests: The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: AEH is a consultant for Proximie. SKD, ALG, and WGT do not have any competing interests to disclose relevant to content within the submitted manuscript.
Funding: The authors received no financial support for the research, authorship and/or publication of this article.
ORCID iDs: Ameer E Hassan https://orcid.org/0000-0002-7148-7616
Sohum K Desai https://orcid.org/0000-0001-6803-3771
Wondwossen G Tekle https://orcid.org/0000-0001-5556-5699
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