For the first time, the audience at the 2019 Charing Cross Symposium (CX; 15–18 April, London, UK) was able to experience an array of virtual reality live cases in both the peripheral and aortic programmes. The virtual reality live streaming in 360° video, accompanied by a running commentary by the operator, provided a novel learning experience.
“With live cases, there is always a risk that one will attempt to reach the limits and the boundaries in favour of achieving an optimal result. Today, however, that was not the case,” stated Frans Moll (Utrecht, The Netherlands) when speaking to Vascular News.
The peripheral virtual reality cases commenced with Thomas Zeller (Bad Krozingen, Germany), live from the Department of Angiology, Universitäts-Herzzentrum Freiburg-Bad Krozingen in Gemany, presenting a directional atherectomy plus drug-coated balloon case using virtual reality in the common femoral artery. Moderating the session from London, Gunnar Tepe (Rosenheim, Germany) navigated the operating room using the swivel of a mouse, driving the camera, and allowing the CX audience to have a different view of the procedure.
The patient in question was a 64-year-old male with claudication (Rutherford 3) in the right leg. Prior to the procedure, the patient underwent revascularisation, with a stent, of the left common iliac artery, in March 2019. Yet, the patient continued to have high-grade stenosis in the right common femoral artery as well as in both the right and left superficial femoral arteries.
Targeting the right common femoral artery, Zeller carried out directional atherectomy with HawkOne (Medtronic). Subsequently, the IN.PACT Admiral drug-coated balloon (Medtronic) was utilised.
From the operator room over 500 miles away, Zeller opened up questions to the CX audience. With one CX delegate coming forward to ask Zeller to comment on the amount of debris captured, Zeller proceeded to empty the device, placing the captured calcified plaque on a cloth, and held it up to the camera for the delegates to witness first-hand.
Following this, the afternoon session launched with Arne Schwindt and Charlotte Köhler demonstrating a live case of a new balloon-expandable endoprothesis from St Franziskus-Hosptial, Münster, Germany.
“A big advantage of this session was that it was not showing a straightforward case,” said Moll, who chaired the session. “Instead, it demonstrated options to bail out from difficult situations that are created, initially, non-intentionally, during the procedure.”
Moll speculated that although the audience may have seen this more complicated case as a problem, he highlighted that the team back in Münster understood the consequences and solved the problem, and ultimately achieved a good outcome.
The procedure itself was an ultrasound-guided bifemoral puncture and insertion of 8F 10cm sheaths. Schwindt also carried out a recanalisation of chronic total occlusion with a 0.035-inch catheter and wire. The 68-year-old female patient is a heavy smoker with arterial hypertension. Köhler also told the CX audience that she has had trophic lesions on the left foot, while the ankle-brachial index was 0.45 right side, and 0.2 left side. No palpable pulses were present on the left wide, although a weak palpable inguinal pulse was present on the right, but no further peripheral pulses palpable. Preoperative imaging with CT angiography had showed aortobiliac occlusion with severe calcification, particularly on the left common iliac artery.
Percutaneous transluminal angioplasty and kissing stenting by use of balloon-expandable covered stents was carried out, with unconnected rings from stainless-steel (VBX, Gore), 8x79mm bilateral.
Despite a complication arising midway through this case, Moll maintained that from a learning point, these live cases demonstrated the benefits of virtual reality in the vascular setting. He acknowledged that they have been well received so far: “They help stimulate discussion. However, [virtual reality] is not yet crystal clear as to what the final position is of this kind of education.”
Throughout the day, a number of edited cases were also presented. While the IN.PACT drug-coated balloon in arteriovenous access was presented by Andrew Holden (Auckland, New Zealand), Trevor Cleveland (Sheffield, UK) highlighted through these case sessions that crossing occlusions for endovascular treatments remains a challenge.