Simulation versus theoretical learning for the transradial approach: a randomized controlled trial in interventional cardiology


Aymen Noamen
Ahmed Ben Amara
Mokhles Lajmi
Nadhem Hajlaoui
Wafa Fehri


Introduction : Simulation-based education (SE) in interventional cardiology improves knowledge acquisition and mastery of procedures
including the conventional radial access (CRA).
Aim: To evaluate the contribution of SE in CRA compared with theoretical learning alone.
Methods : This is a prospective randomized controlled study including cardiology residents and patients with normal radial pulses. Experienced residents as well as patients with contraindications to CRA, requiring urgent intervention, or with hemodynamic instability were not
included. Missing the teaching sessions was the exclusion criteria. Residents were randomized into two groups: simulation versus control.
They attended a theory lecture explaining CRA and were evaluated Only the simulation group attended an SE session with measurement
of heart rate (HR) and stress level. A real application was then performed with measurement of HR and stress level. The primary outcome
was success puncture rate.
Resulats : The success of the puncture was similar between the two groups (p=0.651). In the practical application, the stress level was
significantly different before the procedure but similar after the end of the procedure. The stress level varied significantly within the same
group before and after the procedure The simulation group was significantly less tachycardic both before and during the procedure with a
significant difference between the two groups (p<10-3).
Conclusion: This study demonstrated the interest of SE in novice residents for CRA as a complement to theoretical learning upstream
of the real-life procedure.


Simulation, training, learning, teaching, radial artery, vascular access, coronarography, evaluation, stress.



  1. Pezel T, Coisne A, Picard F, Gueret P, French Commission of Simulation Teaching of the French Society of Cardiology. How simulation teaching is revolutionizing our relationship with cardiology. Arch Cardiovasc Dis. 2020;113(5):297‑302. DOI: 10.1016/j.acvd.2020.03.010
  2. Okuda Y, Bryson EO, DeMaria S, et al. The utility of simulation in medical education: what is the evidence? Mt Sinai J Med N Y. 2009;76(4):330‑43. DOI: 10.1002/msj.20127
  3. Pezel T, Coisne A, Bonnet G, et al. Simulation-based training in cardiology: State-of-the-art review from the French Commission of Simulation Teaching (Commission d’enseignement par simulation-COMSI) of the French Society of Cardiology. Arch Cardiovasc Dis. 2021;114(1):73‑84. DOI: 10.1016/j.acvd.2020.10.004
  4. Gosai J, Purva M, Gunn J. Simulation in cardiology: state of the art. Eur Heart J. 2015;36(13):777‑83. DOI: 10.1093/eurheartj/ehu527
  5. Jp C, H T, E B, et al. 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J. Eur Heart J; 2021;42(14). DOI: 10.1093/eurheartj/ehaa575
  6. Kolkailah AA, Alreshq RS, Muhammed AM, Zahran ME, El‐Wegoud MA, Nabhan AF. Transradial versus transfemoral approach for diagnostic coronary angiography and percutaneous coronary intervention in people with coronary artery disease. Cochrane Database Syst Rev. John Wiley & Sons, Ltd; 2018;(4). DOI: 10.1002/14651858.CD012318.pub2
  7. Mahmoudi A, Noomen F, Nasr M, Zouari K, Hamdi A. [Evaluation of residency training in general and digestive surgery in Tunisia]. Pan Afr Med J. 2015;21:328. DOI: 10.11604/pamj.2015.21.328.6604
  8. Naouar S, Binous MY, Braiek S, El Kamel R. Training of Tunisian future urologists: how to improve it ? Tunis Med. 2018;96(7):401‑4.
  9. Zairi I, Mzoughi K, Mrad IB, et al. Intérêt de la simulation dans l’apprentissage du raisonnement clinique The value of simulation in learning clinical reasoning. Tunis Med. 2020; 98 (06) : 466-9.
  10. Ahmed HB, Ouanes I, Allouche E, Chetoui A, Ouechtati W, Bazdeh L. Évaluation du stress généré par un exercice de simulation haute-fidélité chez des étudiants en médecine Assessement of stress induced by high-fidelity simulation sessions among medical students. Tunis Med. 2020;98(05) : 363-7.
  11. Ben Amara A, Noamen A, Anouar Y, Chenik S, Hajlaoui N, Fehri W. Evaluation of the Distal Radial Approach in percutaneous coronary interventions. Controlled, randomized non-inferiority trial. Tunis Med. 2022;100(3):192‑202.
  12. Gauthier J, Bouchard S. Adaptation canadienne-française de la forme révisée du State–Trait Anxiety Inventory de Spielberger. Can J Behav Sci Rev Can Sci Comport. 1993;25(4):559‑78. DOI: 10.1037/h0078881
  13. Yuan HB, Williams BA, Fang JB, Ye QH. A systematic review of selected evidence on improving knowledge and skills through high-fidelity simulation. Nurse Educ Today. 2012;32(3):294‑8. DOI: 10.1016/j.nedt.2011.07.010
  14. Fischer Q, Sbissa Y, Nhan P, et al. Use of Simulator-Based Teaching to Improve Medical Students’ Knowledge and Competencies: Randomized Controlled Trial. J Med Internet Res. 2018;20(9):e261. DOI: 10.2196/jmir.9634
  15. Henriksen MJV, Wienecke T, Kristiansen J, Park YS, Ringsted C, Konge L. Opinion and Special Articles: Stress when performing the first lumbar puncture may compromise patient safety. Neurology. 2018;90(21):981‑7. DOI: 10.1212/WNL.0000000000005556
  16. Bauer C, Rimmelé T, Duclos A, et al. Anxiety and stress among anaesthesiology and critical care residents during high-fidelity simulation sessions. Anaesth Crit Care Pain Med. 2016;35(6):407‑16. DOI: 10.1016/j.accpm.2016.01.004
  17. Gurm HS, Sanz-Guerrero J, Johnson DD, et al. Using simulation for teaching femoral arterial access: A multicentric collaboration. Catheter Cardiovasc Interv Off J Soc Card Angiogr Interv. 2016;87(3):376‑80. DOI: 10.1002/ccd.26256
  18. Okano H, Mayumi T, Kataoka Y, et al. Outcomes of Simulation-Based Education for Vascular Access: A Systematic Review and Meta-Analysis. Cureus. 2021;13(8):e17188. DOI: 10.7759/cureus.17188
  19. Oh EJ, Lee J-H, Kwon EJ, Min JJ. Simulation-based training using a vessel phantom effectively improved first attempt success and dynamic needle-tip positioning ability for ultrasound-guided radial artery cannulation in real patients: An assessor-blinded randomized controlled study. PloS One. 2020;15(6):e0234567. DOI: 10.1371/journal.pone.0234567
  20. Harrison CM, Gosai JN. Simulation-based training for cardiology procedures: Are we any further forward in evidencing real-world benefits? Trends Cardiovasc Med. 2017;27(3):163‑70. DOI: 10.1016/j.tcm.2016.08.009
  21. Popovic B, Pinelli S, Albuisson E, et al. The Simulation Training in Coronary Angiography and Its Impact on Real Life Conduct in the Catheterization Laboratory. Am J Cardiol. 2019;123(8):1208‑13. DOI: 10.1016/j.amjcard.2019.01.032
  22. Prenner SB, Wayne DB, Sweis RN, Cohen ER, Feinglass JM, Schimmel DR. Simulation-based education leads to decreased use of fluoroscopy in diagnostic coronary angiography. Catheter Cardiovasc Interv Off J Soc Card Angiogr Interv. 2018;91(6):1054‑9. DOI: 10.1002/ccd.27203
  23. Yang L, Li Y, Liu J, Liu Y. Effect of vascular simulation training on practice performance in residents: a retrospective cohort study. BMJ Open. 2020;10(9):e037338. DOI: 10.1136/bmjopen-2020-037338
  24. Hale C, Crocker J, Vanka A, Ricotta DN, McSparron JI, Huang GC. Cohort study of hospitalists’ procedural skills: baseline competence and durability after simulation-based training. BMJ Open. 2021;11(8):e045600. DOI: 10.1136/bmjopen-2020-045600
  25. Joshi A, Wragg A. Simulator Training in Interventional Cardiology. Interv Cardiol Lond Engl. 2016;11(1):70‑3. DOI: 10.15420/icr.2016.11.1.70
  26. Weber U, Zapletal B, Base E, Hambrusch M, Ristl R, Mora B. Resident performance in basic perioperative transesophageal echocardiography: Comparing 3 teaching methods in a randomized controlled trial. Medicine (Baltimore). 2019;98(36):e17072. DOI: 10.1097/MD.0000000000017072
  27. Ferrero NA, Bortsov AV, Arora H, et al. Simulator training enhances resident performance in transesophageal echocardiography. Anesthesiology. 2014;120(1):149‑59. DOI: 10.1097/ALN.0000000000000063
  28. Hernández-Padilla JM, Granero-Molina J, Márquez-Hernández VV, Cortés-Rodríguez AE, Fernández-Sola C. Efeitos de um workshop de simulação sobre a competência em punção arterial de estudantes de enfermagem. Acta Paul Enferm. Escola Paulista de Enfermagem, Universidade Federal de São Paulo; 2016;29:678‑85. DOI: 10.1590/1982-0194201600095
  29. Kikuchi M, Asao T, Tokumine J, et al. A novel system for teaching the in-plane vascular access technique: A simulation study. Medicine (Baltimore). 2021;100(37):e27201. DOI: 10.1097/MD.0000000000027201