Commentary to “Assessment of Competence in EVAR Procedures – A Novel Rating Scale Developed by the Delphi Technique”

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In the past two decades the preferred treatment of abdominal aortic aneurysms has changed from open to endovascular aneurysm repair (EVAR). In European countries a steady increase in the use of EVAR has been observed with improved outcomes. To evaluate endovascular skills and to standardize the training and performance of trainees, the authors have developed a rating scale to assess these competences in EVAR.3 A panel of 32 international experts have reduced a pool of 83 items to seven pivotal assessment items. The authors proposed a five point Likert scale for each of these items to the final appraisal tool: EVARATE. The research team did a great job to develop this standardised assessment tool, but omitted several items not directly related to the endovascular aortic intervention although essential for proper EVAR outcomes. Moreover, the expert panel voted out several items, which were considered intrinsic to other endovascular skills. A clear distinction was made between fundamental endovascular skills, identified in a recent Delphi consensus study, and advanced procedure specific skills.4 The fundamental endovascular skills were considered requisite before being allowed to perform EVAR. Consequently, EVARATE is a procedure specific evaluation tool limited to deployment of a modular infrarenal aortic stent graft. Key elements of stent graft placement and deployment can be assessed, but other important aspects of EVAR, like planning and sizing, taking care of the access arteries (puncture skills and use of closure devices) and radiation protection are not addressed. Also, more advanced skills like troubleshooting (to overcome stenosed access arteries and endovascular adjuncts in case of acute type IA endoleaks) and performing chimney and fenestrated EVARs cannot be evaluated. In the footsteps of EVARATE, additional assessment tools for all procedural steps must be developed to cover a complete trainee appraisal of real world EVAR competence including more hostile aortic and iliac anatomy. Although the selection of the assessment items has been done thoroughly, the evaluation method using a Likert scale has yet to be validated. A Likert scale may be arbitrary, using subjective descriptors of quality like “unacceptable”, “acceptable”, and ‘superior’. Also, the assessment of the level of trainee independence performing the several procedural steps is lacking. The latter is essential to allow trainees to perform EVAR procedures with less supervision during their training. In conclusion, EVARATE contains well selected assessment items that can be used for structured feedback and measuring the progress of EVAR training. After validation of this assessment tool for the deployment of aortic stent grafts, EVARATE may be used as a necessary blueprint for developing additional evaluation tools for all aspects of EVAR.