Perfused Cadaver Model Research Articles

4D Printing of Bioartificial, Small‐Diameter Vascular Grafts with Human‐Scale Characteristics and Functional Integrity

AbstractA novel developed 4D bioprinting technique is used for the manufacturing of human‐scale, small‐diameter vascular grafts. Accordingly, a bio‐ink is synthesized from a hybrid molecule containing sodium alginate (SA) and collagen peptide (COP). Endothelial progenitor cells (EPC) isolated from human whole blood are integrated into the bioartificial vascular graft as an autologous cell source. Likewise, human umbilical vein endothelial cells (HUVEC) are used as experimental standard. The evolving vascular grafts are printed by a customized 4D bioprinter into CaCl2 support medium for rapid cross‐linking inducing the temporospatial shaping of the grafts. After culturing for 21 days, histological and ultrastructural analyses of the bioartificial vascular grafts reveal a well‐organized matrix with imbedded EPC or HUVEC. Live‐3D‐cell–imaging and cell viability assays demonstrate a multitude of vital and metabolically active cells. Biomechanics of the grafts are proven to be comparable to human saphenous veins. Coagulation analysis reveals low thrombogenicity and high functional integrity of the vascular grafts. Surgical implantation of the grafts in a perfused cadaver model can be performed effectively and without technical issues. Finally, the current study describes for the first time the 4D bioprinting and characterization of a small‐diameter, human‐scale vascular graft for putative clinical translation.

Combined Thyroid-Parathyroid Organ Transplantation: Demonstration of Technical Feasibility in a Perfused Cadaver Model.

Combined Thyroid-Parathyroid Organ Transplantation: Demonstration of Technical Feasibility in a Perfused Cadaver Model.

Mixed reality surgical mentoring of combat casualty care related procedures in a perfused cadaver model: Initial results of a randomized feasibility study

BackgroundMost telemedicine modalities have limited ability to enhance procedural and operative care. We developed a novel system to provide synchronous bidirectional expert mixed reality-enabled virtual procedural mentoring. In this feasibility study, we evaluated mixed reality mentoring of combat casualty care related procedures in a re-perfused cadaver model. MethodsNovices received real-time holographic mentoring from experts using augmented reality via Hololens (Microsoft Inc, Redmond, WA). The experts maintained real-time awareness of the novice’s operative environment using virtual reality via HTC-Vive (HTC Corp, Xindian District, Taiwan). Additional cameras (both environments) and novel software created the immersive, shared, 3-dimensional mixed reality environment in which the novice and expert collaborated. The novices were prospectively randomized to either mixed reality or audio-only mentoring. Blinded experts independently evaluated novice procedural videos using a 5-point Likert scale-based questionnaire. Nonparametric variables were evaluated using the Wilcoxon rank-sum test and comparisons using the χ2 analysis; significance was defined at P < .05. ResultsSurgeon and nonsurgeon novices (14) performed 69 combat casualty care-related procedures (38 mixed reality, 31 audio), including various vascular exposures, 4-compartment lower leg fasciotomy, and emergency neurosurgical procedures; 85% were performed correctly with no difference in either group. Upon video review, mixed reality–mentored novices showed no difference in procedural flow and forward planning (3.67 vs 3.28, P = .21) or the likelihood of performing individual procedural steps correctly (4.12 vs 3.59, P = .06). ConclusionIn this initial feasibility study, our novel mixed reality-based mentoring system successfully facilitated the performance of a wide variety of combat casualty care relevant procedures using a high fidelity re-perfused cadaver model. The small sample size and limited variety of novice types likely impacted the ability of holographically mentored novices to demonstrate improvement over the audio-only control group. Despite this, using virtual, augmented, and mixed reality technologies for procedural mentoring demonstrated promise, and further study is needed.

Efficacy of a perfused cadaver model for simulated trauma resuscitation in advanced surgical skills training

BackgroundTo develop a perfused cadaveric model for trauma surgery simulation, and to evaluate its efficacy in trauma resuscitation advanced surgical skills training.MethodsFourteen fourth-year general surgery residents attended this workshop at Siriraj Hospital (Bangkok, Thailand). Inflow and outflow cannulae and a cardiopulmonary bypass pump were used to create the perfusion circuit. Inflow was achieved by cannulating the right common carotid artery, and outflow by cannulation of both the right common femoral artery and the internal jugular vein. Arterial line monitoring was used to monitor resuscitation response and to control perfusion pressure. The perfusion solution comprised saline solution mixed 1:1 with glycerol (50%) and water with red food dye added. Advanced surgical skills during life-threatening injuries and damage control resuscitation operations were practiced starting from the airway to the neck, chest, peripheral vessels, abdomen, and pelvis. Resuscitative endovascular balloon occlusion of the aorta (REBOA) was also practiced. Post-workshop survey questions were grouped into three categories, including comparison with previous training methods; the realism of anatomical correlation and procedures; and, satisfaction, safety, and confidence. All questions and tasks were discussed among all members of the development team, and were agreed upon by at least 90% of experts from each participating medical specialty/subspecialty.ResultsThe results of the three main groups of post-workshop survey questions are, as follows: (1) How the training compared with previous surgical training methods—mean score: 4.26/5.00, high score: 4.73/5.00; (2) Realism of anatomical correlation and procedures—mean score: 4.03/5.00, high score: 4.60/5.00; and, (3) Satisfaction, safety, and confidence—mean score: 4.24/5.00, high score: 4.47/5.00.ConclusionThe developed perfused cadaveric model demonstrated potential advantages over previously employed conventional surgical training techniques for teaching vascular surgery at our center as evidenced by the improvement in the satisfaction scores from students attending perfused cadaveric training compared to the scores reported by students who attended earlier training sessions that employed other training techniques. Areas of improvement included ‘a more realistic training experience’ and ‘improved facilitation of decision-making and damage control practice during trauma surgery’.

A-32 | Effect of Pulsatile Intravascular Lithotripsy in Various Calcium Morphologies

Eccentric vascular calcifications remain a challenge to fragment. In this study, pulsatile-intravascular lithotripsy (P-IVL) technology was assessed for its ability to fragment various calcium morphologies in a perfused cadaver model.

Performance Evaluation of the Solo-T and the Combat Application Tourniquet in a Perfused Cadaver Model.

We evaluated a 10.2-cm-wide, minimally elastic, adhesive wrap-based tourniquet (Solo-T or ST) alongside a 3.8-cm-wide windlass-based tourniquet (Combat Application Tourniquet Generation 7, or CAT) to determine if the tension wrap-tightened ST could deliver hemorrhage control equivalent to the windlass-tightened CAT. A cadaver model was used to simulate lower-thigh femoral arterial hemorrhage at "normal" (146 ± 5mmHg) and "elevated" (471 ± 3mmHg) perfusion pressures (mean ± standard error). Three study participants used the ST and CAT to control hemorrhage during 48 timed trials. Arterial occlusion was established by Doppler ultrasound and tourniquet performance was quantified by under-tourniquet pressure cuffs. Participants achieved 100% (24/24) occlusion success rates and reported similar ease of use for both tourniquets. Occlusion and application times (mean ± standard error) were similar (p > .05) for the ST and CAT under "normal" (occlusion, ST: 25 ± 2 seconds, CAT: 22 ± 2 seconds; application, ST: 27 ± 2 seconds, CAT: 26 ± 2 seconds) and "elevated" (occlusion, ST: 24 ± 7 seconds, CAT: 24 ± 7 seconds; application, ST: 25 ± 7 seconds, CAT: 25 ± 7 seconds) perfusion alike. The ST mean completion pressures (mean ± standard error) were > 40% lower than the CAT under both "normal" perfusion (ST: 110 ± 20mmHg; CAT: 210 ± 30mmHg; p = 0.009) and "elevated" perfusion (ST: 190 ± 50mmHg; CAT: 340 ± 30mmHg; p = 0.03). The adhesive wrap-based ST tourniquet delivered equivalent hemorrhage control performance at significantly lower completion pressures than the CAT.

TCT-123 Evaluation of Pulsatile Intravascular Lithotripsy for Controlled Fragmentation of Calcified Plaque in a Perfused Cadaver Model

TCT-123 Evaluation of Pulsatile Intravascular Lithotripsy for Controlled Fragmentation of Calcified Plaque in a Perfused Cadaver Model

Evaluation of the efficacy of commercial and noncommercial tourniquets for extremity hemorrhage control in a perfused cadaver model.

Tourniquets are a critical tool in the immediate response to life-threatening extremity hemorrhage; however, the optimal tourniquet type and effectiveness of noncommercial devices remain unclear. Our aim was to evaluate the efficacy of five tourniquets in a perfused-cadaver model. This prospective study used a perfused-cadaver model with standardized superficial femoral artery injury bleeding at 700 mL/min. Five tourniquets were tested: combat application tourniquet; rapid application tourniquet system; Stretch, Wrap, And Tuck Tourniquet; an improvised triangle bandage windlass; and a leather belt. Forty-eight medical students underwent a practical hands-on demonstration of each tourniquet. Using a random number generator, they placed the tourniquets on the bleeding cadaver in random order. Time to hemostasis, time to secure devices, estimated blood loss, and difficulty rating were assessed. A one-way repeated measures analysis of variance was used to compare efficacy between the tourniquets in achieving the outcomes. The mean ± SD participant age was 25 ± 2.6 years, and 29 (60%) were male. All but one tourniquet was able to stop bleeding, but the rapid application tourniquet system had a 4% failure rate. Time to hemostasis and estimated blood loss did not differ significantly (p > 0.05). Stretch, Wrap, And Tuck Tourniquet required the longest time to be secured (47.8 ± 17.0 seconds), whereas the belt was the fastest (15.2 ± 6.5 seconds; p < 0.001). The improvised windlass was rated easiest to learn and apply, with 22 participants (46%) assigning a score of 1. Four of five tourniquets evaluated, including both noncommercial devices, effectively achieved hemostasis. A standard leather belt was the fastest to place and was able to stop the bleeding. However, it required continuous pressure to maintain hemostasis. The improvised windlass was as effective as the commercial devices and was the easiest to apply. In an emergency setting where commercial devices are not available, improvised tourniquets may be an effective bridge to definitive care.

Brief report on combat trauma surgical training using a perfused cadaver model.

Surgical combat casualty care presents difficult training challenges. Although several high-fidelity simulation (SIM) techniques have emerged, none are able to fully integrate the many intricacies involved in the care of a complex trauma patient. Herein, we report the use of perfused fresh human cadaver model for training and assessment of forward surgical teams (FSTs). Forward surgical teams attend a 4-day combat trauma surgical skills course including focused on trauma exposures. A half-day SIM involves the entire surgical team in four sequential surgical scenarios that involve the neck, chest, abdomen, and extremities, as well as airway management and resuscitation. Teams undergo immediate debriefing and videotape review of team dynamics and technical skills, as well as times to completion of critical interventions. The data evaluated include five initial demonstration courses in which training metrics were available. Each team included both a junior and experienced surgeon, anesthesiologists, and surgical scrub technicians. As FSTs progressed through SIMs, they demonstrated improvements in team dynamics and technical skills evaluations. There was considerable variability in the times to completion of critical intervention, particularly for control of cardiac and vascular injuries. Initial evaluations support the use of this novel perfused cadaver model for the training and evaluation of military FSTs. Preliminary data highlight the utility for open vascular, thoracic, and other high-acuity/low-volume procedures critical to combat casualty care. Larger studies are needed for model optimization and further validation of an objective structured technical assessment tool. Care management, level V.

CADAVERIC ECMO CANNULATION SIMULATOR

Extracorporeal cardiopulmonary resuscitation (ECPR) is a high stakes low opportunity event which involves cannulating and initiating ECMO support in the arresting patient. In response to recent evidence suggesting ECPR can drastically improve neurologic outcome for refractory cardiac arrest, this technology is more frequently being employed in the emergency department for out of hospital arrests. 1-2 Optimal initiation of ECMO in this setting requires the cooperation of multiple team members with varied backgrounds. This is best facilitated by education and deliberate practice via simulation activity. 1-2 At our institution, simulation with a perfusion-capable mannequin has been used to provide realistic training in areas of crisis resource management related to ECPR, however, the actual technical aspects of cannulation are difficult to simulate. The Dalhousie University Clinical Cadaver Program provides soft-preserved cadavers for high fidelity surgical and technical simulation. While clinical cadavers have been used previously for endovascular procedural training 3-4, we present the first simple novel perfused model capable of realistic venous and arterial ECMO cannulation. All four limbs were secured with trauma tourniquets to maintain fluid within the central vasculature. The right carotid artery and internal jugular vein were accessed through cutdown. Pursestrings were placed on each vessel. The carotid was cannulated with an 8 Fr central venous catheter. An 18 Fr Coude catheter was introduced through the IJ, directed past the right atrium and into the inferior vena cava. Positioning was confirmed with ultrasound. NS was infused under pressure into the arterial and venous systems of the cadaver and femoral cannulation was attempted by physicians with experience in ECPR cannulation. The video shows that the model demonstrated realistic ultrasound images of the femoral artery and vein for cannulation. Fluid remained within the central vasculature long enough to facilitate ultrasound guided cannulation. We were successfully able to introduce arterial and venous cannulas. We demonstrate a perfused cadaver model that provides a realistic cannulation simulation and can be prepared relatively easily. Successful ECPR Programs will require trained physicians who are available to perform this infrequent but technically demanding procedure. Our model could be used to provide training to those physicians. Additionally, our model could be used by Cardiac Surgery Training Programs for simulation of cannulation of other areas.

Costs and training results of an objectively validated cadaveric perfusion‐based internal carotid artery injury simulation during endoscopic skull base surgery

Internal carotid artery injury (ICAI) is a rare, life-threatening complication of endoscopic endonasal approaches (EEAs). High-fidelity simulation methods exist, but optimization of the training cohort, training paradigm, and costs of simulation training remain unknown. Using our previously validated, high-fidelity, perfused-cadaver model, participants attempted to manage a simulated ICAI. After a brief instructional video and coaching, the simulation was repeated. Training success was defined as successful ICAI control on the second attempt after failure on the initial attempt. Marginal costs were measured. Seventy-two surgeons participated in the standardized simulation, which lasted ≤15 minutes. The marginal cost of simulation was $275.00 per surgeon. A total of 44.4% (n = 32) succeeded on the first attempt before training (previously proficient); 44.4% (n = 32) failed the first attempt, but succeeded after training (training successes); and 11.1% (n = 8) failed both attempts. The cost per training success was $618.75. Forty-two surgeons had never treated an ICAI, with 24 becoming training successes (57.1% overall, 82.8% when excluding previously proficient surgeons). Twenty-nine had experienced a real or simulated ICAI, with 8 (27.6% overall, 72.7% excluding previously proficient surgeons) becoming training successes. The cost per training success was lowest in the ICAI-naive group ($481.25) and highest among surgeons with simulated and real ICAI experience ($1650). Surgeons can be trained to manage ICAI in a single, brief, low-cost session. Although all groups improved, training an ICAI-naive or resident cohort may maximize training results. A perfused-cadaver model is a reproducible, realistic, and low-cost method for training surgeons to manage life-threatening ICAI during an EEA.

A Reusable Perfused Human Cadaver Model for Surgical Training: An Initial Proof of Concept Study.

Today's surgical trainees have less exposure to open vascular and trauma procedures. Lightly embalmed cadavers may allow a reusable model that maximizes resources and allows for repeat surgical training over time. This was a three-phased study that was conducted over several months. Segments of soft-embalmed cadaver vessels were harvested and perfused with tap water. To test durability, vessels were clamped, then an incision was made and repaired with 5-0 polypropylene. Tolerance to suturing and clamping was graded. In a second phase, both an arterial-synthetic graft and an arterial-venous anastomosis were performed and tested at 90 mmHg perfusion. In the final phase, lower extremity regional perfusion was performed and vascular control of a simulated injury was achieved. Seven arteries and six veins from four cadavers were explanted. All vessels accommodated suture repair over 6 weeks. There was minor leaking at all previous clamp sites. In the anastomotic phase, vessels tolerated grafting, clamping, and perfusion without tearing or leaking. Regional perfusion provided a life-like training scenario. Explanted vessels of soft-embalmed cadavers show adequate durability over time with realistic vascular surgery handling characteristics. This shows promise as initial proof of concept for a reusable perfused cadaver model. Further study with serial regional and whole-body perfusion is warranted.

A Randomized Controlled Trial using iTClamp, Direct Pressure, and Balloon Catheter Tamponade to Control Neck Hemorrhage inaPerfused Human Cadaver Model.

Penetrating neck wounds are common in the civilian and military realms. Whether high or low velocity, they carry a substantial morbidity and mortality rate. We endeavored to ascertain whether the iTClamp is equivalent to direct manual pressure (DMP) and Foley catheter balloon tamponade (BCT). Using a perfused cadaver, a 4.5-cm wound was made in Zone 2 of the neck with a 1-cm carotid arteriotomy. Each of the hemorrhage control modalities was randomized and then applied to the wound separately. Time to apply the device and fluid loss with and without neck motion was recorded. There was no significant difference between the fluid loss/no movement (p>0.450) and fluid loss/movement (p>0.215) between BCT and iTClamp. There was significantly more fluid lost with DMP than iTClamp with no movement (p>0.000) and movement (p>0.000). The iTClamp was also significantly faster to apply than the Foley (p>0.000). The iTClamp and BCT were associated with significantly less fluid loss than DMP in a perfused cadaver model. The iTClamp required significantly less time to apply than the BCT. Both the iTClamp and the BCT were more effective than simple DMP. The iTClamp offers an additional option for managing hard-to-control bleeding in the neck.

Initial Report on a Damage Control Surgery Course for Military Forward Surgical Teams Utilizing a Novel Perfused Cadaver Model for Training and Evaluation

Initial Report on a Damage Control Surgery Course for Military Forward Surgical Teams Utilizing a Novel Perfused Cadaver Model for Training and Evaluation

A Novel Expeditionary Perfused Cadaver Model for Trauma Training in the Out-of-Hospital Setting

BackgroundCadaver training for prehospital surgical procedures is a valid training model. The limitation to date has been that perfused cadavers have only been used in wet laboratories in hospitals or university centers. We endeavor to describe a transportable central-perfused cadaver model suitable for training in the battlefield environment. Goals of design were to create a simple, easily reproducible, and realistic model to simulate procedures in field and austere conditions. MethodsWe conducted a review of the published literature on cadaver models, conducted virtual-reality simulator training, performed interviews with subject matter experts, and visited the laboratories at the Centre for Emergency Health Sciences in Spring Branch, TX, the Basic Endovascular Skills in Trauma laboratory in Baltimore, MD, and the Fresh Tissue Dissection Laboratory at Los Angeles County and University of Southern California, Keck School of Medicine, Los Angeles, CA. ProcedureThis article will describe a five-step procedure that utilizes extremity tourniquets, right common carotid intra-arterial and distal femur intraosseous (IO) access for perfusion, and oropharynx preparation for airway procedures. The model will then be ready for all tactical combat casualty care procedures, including nasopharyngeal airway, endotracheal intubation, cricothyroidotomy, central-line access, needle decompression, finger and tube thoracostomy, resuscitative endovascular balloon occlusion of the aorta, junctional tourniquets, IO lines, and field amputations. ConclusionsThis model has been used in the laboratory, field, ground ambulance, and military air ambulance (UH-60) settings with good results. The model described can be used in the field setting with minimal resources and accurately simulates the critical skills for all combat trauma procedures.

Feasibility and Proposed Training Pathway for Austere Application of Resuscitative Balloon Occlusion of the Aorta

Noncompressible junctional and truncal hemorrhage remains a significant cause of combat casualty death. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an effective treatment for many junctional and noncompressible hemorrhages. The current hospital standard for time of placement of REBOA is approximately 6 minutes. This study examined the training process and the ability of nonsurgical physicians to apply REBOA therapy in an austere field environment.This was a skill acquisition and feasibility study. The participants for this experiment were two board-certified military emergency medicine physicians with no prior endovascular surgery exposure. Both providers attended two nationally recognized REBOA courses for training. A perfused cadaver model was developed for the study. Each provider then performed REBOA during different phases of prehospital care. Time points were recorded for each procedure.There were 28 REBOA catheter placement attempts in 14 perfused cadaver models in the nonhospital setting: eight placements in a field setting, eight placements in a static ambulance, four placements in a moving ambulance, and eight placements inflight on a UH-60 aircraft. No statistically significant differences with regard to balloon inflation time were found between the two providers, the side where the catheter was placed, or individual cadaver models. Successful placement was accomplished in 85.7% of the models. Percutaneous access was successful 53.6% of the time. The overall average time for REBOA placement was 543 seconds (i.e., approximately 9 minutes; median, 439 seconds; 95% confidence interval [CI], 429-657) and the average placement time for percutaneous catheters was 376 seconds (i.e., 6.3 minutes; 95% CI, 311-44 seconds) versus those requiring vascular cutdown (821 seconds; 95% CI, 655-986). Importantly, the time from the decision to convert to open cutdown until REBOA placement was 455 seconds (95% CI, 285-625).This study demonstrated that, with proper training, nonsurgical providers can properly place REBOA catheters in austere prehospital settings at speeds.

Continuous Flow Perfused Cadaver Model for Endovascular Training, Research, and Development

Endovascular simulation employing computer, animal, and static models are common and useful adjuncts for teaching endovascular procedures and developing novel, complex endovascular techniques. Unfortunately, these models lack realistic haptic feedback and thus do not faithfully replicate many of the technical challenges associated with clinical endovascular procedures (e.g., arterial calcification, rigidity, and stenosis). We sought to develop a realistic and reproducible perfused cadaver model for endovascular training, device development, and research. Fresh frozen, elderly (age 50-80 years) male cadavers were thawed and prepared for open dissection. The entire arterial tree (ascending aorta to femoral arteries) was dissected free and major branch vessels exposed. Sheaths were placed to allow outflow from selected vessels. A Dacron conduit was sewn to the ascending aorta to generate arterial inflow, which was provided by a centrifugal pump. Aortic aneurysms were created in the descending thoracic and abdominal aorta. Digital subtraction arteriography and various endovascular interventions were performed, including stent grafts and EndoAnchors deployment. Continuous antegrade flow was achieved in the thoracic, abdominal, iliac, and femoral segments. Open and percutaneous access at the femoral region was obtained with realistic back-bleeding and tactile feedback. Adequate, fluoroscopically documented flow was observed in both cannulated major and noncannulated smaller branches. We performed angiography with standard techniques via a pigtail catheter and contrast injector throughout the arterial system. Abdominal and thoracic endografts were deployed with appropriate angiographic guidance and realistic haptic feedback for both guidewire and stent grafts. Additional applications, including selective cannulation, aorto-iliac occlusive disease interventions, and anchor placement, were also successfully simulated. Finally, the model was used as a platform to test investigational devices. Our pressurized cadaver flow model successfully replicated multiple aspects of advanced endovascular procedures with haptic feedback. This novel human cadaver model allows for training and device development under clinically realistic conditions.

The Development of a Novel Perfused Cadaver Model With Dynamic Vital Sign Regulation and Real-World Scenarios to Teach Surgical Skills and Error Management

AbstractThe landscape of graduate medical education has changed dramatically over the past decade and the traditional apprenticeship model has undergone scrutiny and modifications. The mandate of the 80-hour work-week, the introduction of integrated residency programs, increased global awareness about patient safety along with financial constraints have spurred changes in graduate educational practices. In addition, new technologies, more complex procedures, and a host of external constraints have changed where and how we teach technical and procedural skills. Simulation-based training has been embraced by the surgical community and has quickly become an essential component of most residency programs as a method to add efficacy to the traditional learning model.The purpose of this paper is twofold: (1) to describe the development of a perfused cadaver model with dynamic vital sign regulation, and (2) to assess the impact of a curriculum using this model and real world scenarios to teach surgical skills and error management. By providing a realistic training environment our aim is to enhance the acquisition of surgical skills and provide a more thorough assessment of resident performance.Twenty-six learners participated in the scenarios. Qualitative data showed that participants felt that the simulation model was realistic, and that participating in the scenarios helped them gain new knowledge, learn new surgical techniques and increase their confidence performing the skill in a clinical setting. Identifying the importance of both technical and nontechnical skills in surgical education has hastened the need for more realistic simulators and environments in which they are placed. Team members should be able to interact in ways that allow for a global display of their skills thus helping to provide a more comprehensive assessment by faculty and learners.

Simulating Internal Carotid Artery Injury during Transsphenoidal Transclival Endoscopic Surgery in a Perfused Cadaver Model.

Introduction Managing internal carotid artery (ICA) injury during extended endoscopic transsphenoidal surgery is an extreme challenge. We aimed to find a possible surgical treatment strategy. Methods We operated seven fresh, perfused cadaver heads with a transsphenoidal endoscopic approach of the ICA using a three-dimensional-high definition (3D-HD) endoscope. We made a paraclival ICA leak, which we tried to manage with clips and microsutures. Results Accurate transsphenoidal clip application on the ICA was impossible with standard aneurysm clips and applier. It was only feasible with a 9 mm slightly bended clip that could be opened from the inside and be applied with a dedicated flexible thin applier. Transsphenoidal suturing of an ICA leak was impossible from the ipsilateral nostril or with standard microinstruments. Suturing was only feasible from the contralateral nostril using flexible microinstruments with a thin 90-mm shaft. This was technically very challenging and involved a steep learning curve. Conclusion Tamponade with muscle or fat and a quick transfer to the angiography suite for endovascular control remains the preferable option in case of an ICA leak during endoscopic transsphenoidal surgery. If tamponade gives insufficient initial control, ICA clipping could be possible with dedicated instruments, with risk of increasing the defect, stenosis, or occlusion of the vessel. Transsphenoidal ICA suturing remains extremely difficult, and laboratory practice seems essential.

Management of Intraoperative Aneurysmal Rupture: Is there a Way to Practice and Simulate it in the Lab?

Introduction: Intraoperative rupture of an intracranial arterial aneurysm represents a feared and sometimes disastrous complication. The incidence rates vary between 6 and 40% of cases, recent studies referred to a rate of 9.2%—the risk of intraoperative rupture is affected by aneurysm location, subarachnoid hemorrhage, temporary arterial occlusion, and certainly to the surgeon's experience and technical skills. Here, we present a cadaveric training model to prepare residents on how to manage intraoperative aneurysmal ruptures. Methods: Artificial aneurysms were modeled and placed in the anterior circulation (MCA, ICA bifurcation, and paraclinoid region, PcomA) on cadaver heads especially prepared according to the “Live Cadaver” (Perfused Cadaver model, ANI, Little Rock, United States). Overall 40 residents were theoretically and practically trained on how to deal with intraoperative aneurysm rupture. Different clipping tenets and technical strategies were demonstrated and practiced. The practical steps consisted in approaching and dissecting the cadaveric aneurysm model, the simulation of the clipping procedure was performed under unruptured and ruptured conditions. Results: The vast majority of the residents performed the clipping procedure adequately and correctly. Even less experienced residents with few or no microvascular skills showed a fast learning curve, felt more self-confident with the handling of instruments and clips, and, according to their feedback, confirmed the importance of practicing microsurgical skills in the laboratories using simulation. Conclusion: The “Live Cadaver” is a unique and realistic training and simulation tool for the management of intraoperative vascular injuries and aneurysmal rupture.