名媛直播

Establishing an endovascular therapy (EVT) program at a cardiology cath lab could be done with a minimal learning curve if operators had prior experience with carotid stenting, one tertiary university hospital reported.

The program, started in 2012 with the addition of an experienced interventional radiologist as lead operator, had stroke patients achieve good clinical outcomes at 90 days in 47.9% of cases.

Importantly, the distribution in modified Rankin Scale (mRS) scores stayed stable every year through 2019, according to Jakub Sulenko, MD, PhD, of Charles University and University Hospital Kralovske Vinohrady in Prague, Czech Republic, and colleagues in the PRAGUE-16 group.

"When a catheter-based thrombectomy program was initiated in an experienced cardiac cath lab in close cooperation between cardiologists, neurologists, and radiologists, outcomes were comparable to those of neuroradiology centers," Sulenko and colleagues concluded in .

"These results are even more astonishing as PRAGUE-16, in contrast to the randomized trials, also included patients with ischemia in the posterior circulation in their analysis," commented Marius Hornung, MD, and Horst Sievert, MD, both of the CardioVascular Center Frankfurt.

"By caring for patients with MI, the physicians involved are comfortable working in critical situations and under mental and physical pressure. We are currently at a time when many experienced cardiologists are also trained in performing carotid artery interventions. Therefore, they are experienced in accessing the supra-aortic arteries," Hornung and Sievert said in an .

The Prague cath lab operated every day and at all hours treating acute MIs before it started taking in acute ischemic stroke patients.

EVT complication rates included 5.7% symptomatic intracerebral hemorrhage and 1.8% embolization in a new vascular territory.

"These findings support the potential role of interventional cardiac cath labs in the treatment of acute stroke in regions where this therapy is not readily available due to the lack of neurointerventionalists," Sulenko's group said, citing a smaller, similar experience from a Pennsylvania center.

At the beginning of the Prague EVT program, two cardiologists with experience in carotid artery stenting (one with 42 procedures, the other with >100) were selected to perform around 30 mechanical thrombectomies under supervision of the newly arrived interventional radiologist. Subsequently, the cardiologists were able to perform thrombectomies without supervision.

A neurologist always decided which patients got stroke thrombectomy based on clinical symptoms and CT angiography.

"To be able to guarantee optimized stroke therapy as soon as possible, disputes over competence among the individual medical societies involved must be ended, and interdisciplinary teams must be created to be able to offer the best possible treatment for each patient," according to Hornung and Sievert.

"Diagnostics, patient selection, and follow-up care must remain the core competencies and tasks of neurology. Appropriately trained and experienced physicians, regardless of their specialties, should perform acute stroke interventions and endovascular thrombectomy," they urged.

The Prague experience included 333 patients with a large vessel occlusion stroke from 2012 to 2019.

Number of EVTs increased from four in 2012 to 82 in 2019. Patients were older over time, from an average of 60 to 72.

Some evidence for a learning curve was observed, as the rate of successful recanalization (TICI grade 2b/3) improved over time from a low of 60% in 2013 to a high of 84% in 2019 (P=0.047). Overall, operators achieved TICI 2b/3 in 79.3% of patients.

A study limitation was its single-center nature.

"The results of PRAGUE-16 show that experienced interventional cardiologists can perform endovascular stroke interventions and thrombectomy with a high degree of technical and clinical success after appropriate training and supervision," Hornung and Sievert maintained.

Only with a larger network of stroke interventionalists, they suggested, can clinicians stop "losing unnecessary time to patient transfer" or "continuing to offer only the second best therapy" to eligible stroke patients.

Comment