Cognitive Task Analysis of Lower Extremity Angiography Interpretation and Intraoperative Decision-Making

Lower extremity angiography interpretation and treatment planning involve complex decision-making. Traditional experiential training is limited by duty hours and concerns about radiation exposure. Expert interpretation processes can be automated bypassing consciousness with heuristics often unintentionally omitted. This study used cognitive task analysis (CTA) to identify and structure the unvoiced expert heuristics used in angiography interpretation and procedure planning.

A CTA framework was utilized. An environmental analysis was conducted, followed by knowledge elicitation via semi-structured, "think-aloud" interviews with attending vascular surgeons. Experts used angiography videos for stimulated recall to narrate real-time decision-making. Data was transcribed, double-coded, and analyzed using inductive qualitative content analysis, filtering into content units. Thematic analysis was performed within units.

Eight interviews reached thematic saturation. The universally emphasized theme was that treatment aggressiveness is dictated by clinical indications, patient comorbidities, and pre-operative imaging, not strictly intraoperative lesion characteristics. Experts reserved conservative algorithms for claudication to preserve bypass targets, while treating chronic limb-threatening ischemia aggressively to achieve inline flow to the foot or specific angiosome. Inductive analysis extracted covert heuristics into a structured angiographic interpretation checklist (image orientation, anatomical survey, dynamic flow assessment).

Treatment decisions based on angiography, disease severity, and patient comorbidities are complex, relying on expert heuristics often unarticulated to novices. After elucidating the covert cognitive frameworks via CTA, we developed the framework of a curriculum and review exercise to facilitate deliberate practice. The ultimate goal is to enable trainees to safely practice pattern recognition and justify decisions in a low-risk environment, mitigating modern operating room pressures.