Carotid artery stenting is a procedure whose success mostly depends on the operator's technical skill.
To give interventional radiologists, vascular surgeons, cardiologists and neurologists the possibility to review, repeat, reasses their ability to perform this procedure, simulators have become a component of their medical training.
The basic aim of a simulator training program is to help any trainee feel more competent and confident because experienced physicians can enrich and improve their knowledge whereas novice can perform the procedure with no safety risk prior to actual patient contact.
Some studies from the literature have highlighted that endovascular experience greatly improves when associated with proctored simulator training sessions because operators achieve a practical skill that makes procedure time shorter for the benefit of patients' clinical conditions and successful results more reliable.
Recent studies have pointed out that the ability to avoid errors of an operator trained on a simulator is undoubtedly higher when compared to the ability of a practitioner trained by traditional methods.
As a matter of fact the demand for simulation education is steadily rising with a preference for proctored cases where the liability of using patients as training material is decreased.

Simulator training offers several advantages that are clear and important.
Simulators allow easy access to a variety of clinical events from the least complex to the most severe and adverse in an encouraging and stimulating environment because any participant can actively develop training opportunities, such as procedure repetition until proficiency is achieved, without causing harm or danger to anyone.
In fact the core components of the procedure can be repeated and practiced countless times according to the operator's request and the trainer's advice.
Each trainee - or team of individuals who use to work together - is required to perform the procedure with the help of realistic tools.
After learning how to use equipment and devices, the operator is trained "to get a feel" for the tactile, visual and clinical elements of a straightforward procedure in an average patient.
A simulator training program allows the attendees to learn how to evaluate the duration of various segments of the procedure, how to select the most appropriate devices and the most correct size of balloons and stents, how to handle unforeseen problems, how to manage medical treatments.
But it is clear that the program final target will be achieved only if trainees understand that a simulator can't be mistaken for a "Play-station".
Like airline pilots who spend hours at simulators to become familiar with any possible manoeuvre and to achieve that personal experience essential for passengers' life, in the same way an attendee is requested to use imagination and reproduce in his mind a demanding reality in an angio-suite or operating theatre at a patient's bedside where the only aim is to perform a successful procedure using the most suitable tools, administering the lowest amount of contrast media, reducing the exposure time as well as the procedure length.

Nowadays medical simulators are considered as a component of medical training and more than 40 virtual reality, graphical and mannequin and screen based simulators are available for initial and ongoing training of health care professionals.
Simulators are now routinely utilized for training in endovascular procedures, anaesthesiology, ophthalmology, laparoscopy and endoscopy.
High tech simulators, based on complex haptics technology integrated with interactive imaging software, have been introduced to the area of percutaneous vascular interventions including carotid stenting, PFO closure and peripheral vascular procedures.
A number of manufacturing companies that develop endovascular simulators are collaborating with at least one major device company and this collaboration has improved a market that continues to grow.
Simulators popularity has spread everywhere but accompanied by several controversial issues.
Simulator training has been criticized being unable to present the trainee with emergent complications when a successful training is supposed to involve not only technical procedural considerations but also the cognitive identification of an unexpected event and immediate decision on an appropriate therapeutic response. This is one of the controversial aspects that make simulation education fall short.
Another matter under discussion is that trainees can work on simulators at a relaxed pace that is helpful for learning the mechanics of a procedure but inconsistent with the real world because pressure and urgency when working on a live patient are quite different.
A further remark is that the educational process is slowed when the computer freezes up or must be rebooted and when the simulator catheter jumps even if advanced smoothly and carefully.
Another discussed problem is that during the training session the operator's tactile sensation remains relatively crude because the simulator doesn't always translate the movement and/or orientation data with proper accuracy.
In fact there may be a lack of one to one movement between the trainee's physical manipulation and what is observed on the monitor.
Last but not least while in a real situation an operator is asked to conveniently sort out and use different tools, in a simulator training only one catheter is utilized in any situation.
Summing up simulators are accused of recreating a "perfect world" and not a real one but critical minds forget that they were planned only to improve medical competence and not to substitute that body of experience that any physician can personally get dealing with a large number of patients, with anatomic and clinical variations, complications and device malfunctions.