Decreasing procedure times with a standardized approach to ELVO cases

Abstract

Background Embolectomy is the standard of care for emergent large vessel occlusion (ELVO), and needs to be done as quickly as possible for the best possible outcomes. Optimization of workflow and process is certainly paramount. One aspect of this is process improvement to standardize as much as possible the procedure in order to decrease variability among operators, which breeds familiarity for the entire team. Objective To evaluate the impact of a standardized approach to ELVO cases in decreasing times from groin puncture to first deployment of a stent-retriever and final recanalization. Methods A retrospective review of 83 consecutive patients consisting of a pre-standardization phase (group 1) and those after standardization (group 2). The standardization process involved all three neurointerventional radiologists agreeing on a standard approach to the cases and to the equipment to be used. Times from groin puncture to first deployment of the stent-retriever and from puncture to final reperfusion were evaluated. Angiographic outcomes were scored using the Modified Thrombolysis in Cerebral Ischemia (mTICI) score. Complications from intracranial catheter manipulation (such as wire perforation) were also recorded. Clinical outcomes were assessed based on admission and discharge National Institute of Health Stroke Scale score. Results There were 22 patients in group 1 and 61 patients in group 2. Mean times from groin puncture to first deployment were 39.8 min in group 1 and 20 min in group 2, a difference which was statistically significant ( p<0.0001). Overall times from puncture to final recanalization were reduced from 68.2 to 37 min, also a statistically significant difference ( p<0.001). There were no cases of intraprocedural complications such as wire perforation or subarachnoid hemorrhage. Conclusions A standardized approach to the equipment used and process for ELVO cases at a single institution can dramatically reduce procedure times.

Endovascular Acute Ischemic Stroke Treatment with FlowGate Balloon Guide Catheter: A Single-Center Observational Study of FlowGate Balloon Guide Catheter Use

“…One advantage that operators consistently appreciated was the ability to use distal access catheters due to its larger inner diameter. The time from groin puncture to recanalization was similar to that reported by ADAPT FAST, perhaps due to a higher FPE, a less complex patient population, or use of only one standard approach, which has been reported by McTaggart et al [17] to improve procedure times.…”

Neuroendovascular management of emergent large vessel occlusion: update on the technical aspects and standards of practice by the Standards and Guidelines Committee of the Society of NeuroInterventional Surgery

“…Additional technical variations and standardized approaches have been reported in the literature noting particular retrieval techniques and/or combinations of reperfusion catheters and stent retrievers 69–73. Whichever techniques are used, standardized approaches can minimize the risk and maximize speedy recanalization 74 . Therefore, in comparing currently available techniques, the superiority of stent retrievers versus thromboaspiration alone, versus combinational techniques, has not been clearly established.…”

STEPS-T Program Improves Endovascular Treatment Outcomes of Acute Ischemic Stroke; A 6-Year Study

“…Clinical outcomes, demonstrated by studies, are heavily reliant on reperfusion times (2,3). In managing AIS cases due to large vessel occlusion, the goal has been to achieve rapid recanalization and to reduce time from onset to mechanical thrombectomy (MT) (4,5). Optimal practices to generate improvement of effective and efficient case management remains immature and lacks a complete consensus, despite technological advancements in managing workflow.…”

“…Studies have demonstrated that modifications and improvements are potentially attainable at every stage of the care workflow, where considerable emphasis has been placed to reduce transport times (4,(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16). The quality of care in AIS has been shown to be influenced by operational modifications such as the implementation of evidence-based stroke protocols, improved staff education and training, and prioritization of hospital resources (17,18).…”