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Objective:
Simulation offers hands-on training for trainees and skill maintenance for trained professionals in a safe environment. This study aims to establish the benefit of simulating uncommon and complex procedures on a customized 3D-printed pediatric endovascular phantom which upgraded to a “plug and play” for the second iteration.

Materials and Methods:
The first iteration 3D model consisted of a generalized, vascular phantom with lower extremity vascular access point for renal angiography, cavography, femoral and jugular supra, infra-renal IVC filter placement and retrieval, coil embolization, coil snare retrieval, and Iliac stent placement. These procedures were simulated over three sessions under fluoroscopic guidance. The second iteration consisted of removable “plug and play” 3D endovascular models that could be inserted into the existing base phantom. An additional vascular access point was added for upper extremity simulation. Lastly, a pump was installed to simulate circulatory flow. This facilitated a further two customized vascular simulations creation, a high-grade renal artery stenosis and a chronic iliac vein stenosis. Participants were provided background clinical information, pertinent literature, and instruction from an experienced pediatric interventional radiology (IR) attending. Procedures were carried out over two, 1-hour sessions under fluoroscopic guidance using expired medical equipment. Simulation steps included: catheter entry via the upper and lower extremity; selective angiography/venography; fluoroscopic overlay for catheter/wire guidance; stenosis identification and transgression; angioplasty and balloon expandable covered stent placement for renal artery stenosis; and self-expandable stent deployment for iliac vein stenosis. Participants then completed a 10-point questionnaire, rating their simulation experience using a 5-point Likert scale (1-strongly disagree to 5-strongly agree).

Results:
All total of 10 procedures were performed by seven participants (1 radiology resident, 3 pediatric IR fellows, and 3 pediatric IR attendings). Specific cases simulated and evaluated included; planned brachial access for renal artery stenosis, cutting balloon angioplasty and stent placement based on three individual patients (age 6-9 years), stent deployment for external iliac vein stenosis based on two patients (age 14 and 17 years), and problem solving for stent misdeployment in an external iliac vein. All operators moderately agreed (Kendal W coefficient 0.5) that the 3D printed phantom provides a realistic procedural experience from catheterization to stenting.

Conclusion:
To our knowledge this is the first pediatric endovascular phantom providing the capability of simulating complex interventions, using a patient specific model with “plug and play” anatomic inserts for patient customization. This platform can provide a stress-free environment for uncommon complex procedural training as well as the ability to simulate a patient focused procedure for planning and execution.