In the closest debate of the Acute Stroke Challenges session that took place on the first day of the Charing Cross (CX) Symposium (15–18 April, London, UK), Jan Kovac (University Hospitals of Leicester NHS Trust, Leicester, UK) and Andrew Clifton (St George’s University Hospitals NHS Foundation Trust, London, UK) discussed whether intracranial thrombectomy should be limited to neurointerventionists.
Kovac, a cardiaologist, whose proposition was that intracranial thrombectomy should not be limited to neurointerventionists, won the debate with 57% of the vote, but a substantial minority (43%) supported Andrew Clifton’s arguments that the procedure should be limited to neurointerventionists.
While Clifton argued that experience and proper training leads to “appropriate patient selection [and] faster, safer procedures with fewer complications”, Kovac said that, given the magnitude of the potential clinical and economic benefits of mechanical thrombectomy, a “collaboration of various interventional specialists is desirable to deliver this therapy to a wider population”.
Kovac argued that “Mechanical thrombectomy is the best evidence-based therapy for acute ischaemic stroke if provided in a timely manner by an experienced, multidisciplinary team.” He went on to say: “There is currently a hiatus between evidence and its implementation into practice across the world, with practice varying significantly within and between countries. For several logistical, practical and economic reasons, collaboration of various interventional specialists is desirable to deliver this therapy to a wider population.”
Indeed, he concluded that, “Given the magnitude of the potential clinical and wider economic benefits from mechanical thrombectomy, it should now be a key priority to address the substantial infrastructure and workforce obstacles impeding rapid and widespread implementation in the UK, Europe and beyond.”
Watch a video here of Martin Radvany (Little Rock, USA) and Joan Wojak (Lafayette, USA) explaining to Interventional News that, as there is a shortage of physicians trained to perform stroke thrombectomy, it is vital for interventionists to acquire the education, training and technical skills specific to stroke therapy.
Intracranial thrombectomy
The debate on intracranial thrombectomy was part of a whole session dedicated to the procedure. Hugh Markus (Cambridge, UK), who was chairing the session, called intracranial thrombectomy “one of the huge advances in stroke care at the moment”. Outlining its significance, he said “for every three patients we treat, we can cure one, so it is a massive treatment effect. It has transformed stroke care.”
In a keynote lecture, David Hargroves (Kent, UK) reviewed what thrombectomy trials “really tell us”, and how the findings can be implemented into routine clinical practice. In light of the DAWN and DIFFUSE-3 trials, he said that there is a strong evidence basis for thrombectomy and that this treatment should be available to all patients. Additionally, Hargroves posited that regional and countrywide networks are required to deliver and achieve its 10% potential reach. However, he said, caution is needed when reorganising stroke services, so as not to destabilise the ‘core’ business and therapeutic benefit of organised care, closest to home.
Virtual reality for training purposes may elucidate “who can do the procedure”
Thomas Liebig (Munich, Germany) looked at the use of virtual reality in thrombectomy training. He described his own training as similar to that of learning to drive a car, and contrasted it with the simulator experiences of pilots who must demonstrate their competencies in a virtual environment. Liebig pointed out that skilled performance is difficult to characterise, and then outlined his work with University College Cork (Republic of Ireland) to develop surrogate parameters for performance metrics that can be used in a simulator. The findings, he said, “have the potential not only for training purposes” but, in a nod to the earlier debate on intracranial thrombectomy, could also allow us to “discriminate between a person who can do the procedure and those who should be doing something else”.
