Direct to angiosuite strategy versus standard workflow triage for endovascular therapy: systematic review and meta-analysis

Abstract

BackgroundReducing stroke workflow times when performing endovascular thrombectomy is associated with improvement in clinical outcomes. We compared outcomes among large vessel occlusion (LVO) stroke patients following the direct to angiosuite (DTAS) strategy versus standard workflow (SW) when undergoing endovascular therapy.MethodsWe conducted a systematic review and meta-analysis to compare rates of functional outcomes, reperfusion, symptomatic intracranial hemorrhage (sICH) and stroke workflow metrics. We included observational studies and clinical trials that compared the DTAS strategy versus SW, and at least one outcome of interest was assessed. Clinical, methodological and statistical heterogeneity were measured, and a random-effects model was used.Results12 studies were included in the systematic review and 8 in the meta-analysis (n=2890). The DTAS strategy was associated with significant higher odds of good functional outcome at 90 days (47.3% vs 34.9%; OR 1.58, 95% CI 1.16 to 2.14) and a significant average reduction of door-to-puncture (mean differences (MD) −35.09, 95% CI −49.76 to −20.41) and door-to-reperfusion times (MD –32.88, 95% CI –50.75 to –15.01). We found no differences in sICH (OR 0.80, 95% CI 0.53 to 1.20), mortality (OR 1.00, 95% CI 0.60 to 1.67) or successful reperfusion rates (OR 1.37, 95% CI 0.82 to 2.29). Moreover, the DTAS strategy was associated with greater odds of dramatic clinical improvement at 24 hours (OR 1.79, 95% CI 1.15 to 2.79).ConclusionPatients undergoing the DTAS strategy had a significant reduction in door-to-puncture and door-to-reperfusion times. This resulted in an increased rate of early neurological and 90-day functional recovery without compromising safety in LVO patients undergoing endovascular thrombectomy.

Cost-utility of direct transfer to angiography suite (DTAS) bypassing conventional imaging for patients with acute ischemic stroke in Spain: results from the ANGIOCAT trial

“…Time from admission to reperfusion has been repeatedly associated with functional outcome and the effect of DTAS reducing this is beyond doubt the reason after the consistent evidence published in the last few years. In the ANGIOCAT trial, although the DTCT group presented a remarkably low median door to puncture time of 42 min, the same interval was only 18 min when the DTAS was followed, similar than previously published in pilot and collaborative studies 7 9 10 17–19. On the other hand, the ANGIOCAT trial is the first study which compared protocols in patients with a confirmed LVO whether or not they received mechanical thrombectomy, and showed that DTAS was associated with an increased rate of EVT (100% of DTAS vs 89% of DTCT patients).…”

“…Similarly, to the percutaneous coronary intervention protocols in acute myocardial infarction, several case–control studies have shown that transporting stroke patients directly to the angiosuite is safe, feasible and results in a significant reduction in median door to treatment times down to 16 min and potentially higher chances of good outcomes 4 6–9. Several meta-analyses10 11 and one randomized clinical trial (ANGIOCAT trial) have recently confirmed these data 12…”

Direct Transfer to the Neuroangiography Suite for Patients With Stroke

“…The data demonstrate a significant decrease in door-to-groin puncture times via the DTA approach (ranging from 29 to 35 minutes). Mohammaden et al and Galecio-Castillo et al 43 also demonstrate functional benefit at 90 days via the DTA approach.…”

“…We identified 10 retrospective studies with at least 25 patients (per study) triaged using the DTA approach (Jadhav et al, 30 Ribo et al, 31 Psychogios et al, 5 Mendez et al, 32 Psychogios et al, 33 Bouslama et al, 34 Requena et al, 35 Mendez et al, 36 Sarraj et al, 37 and Regenhardt et al 38 ) and 2 completed randomized controlled trials (Pfaff et al 39 and Requena et al 40 ; Table 1). Further, we also identified 3 meta-analyses (Brehm et al, 41 Mohammaden et al, 42 and Galecio-Castillo et al 43 ) and 3 ongoing randomized controlled trials (Table 2). 5,[30][31][32][33][34][35][36][37][38] Retrospective Data Table 1 summarizes these studies, characteristics, and results.…”

Current and future trends in acute ischemic stroke treatment: direct-to-angiography suite, middle vessel occlusion, large core, and minor strokes

“…Several meta-analyses have reviewed the results of the DTAS strategy on potential EVT patients compared to classical (DTCT, direct-to-emergency department) pathways [46] , [47] , [48] . All included mixed population groups of transferred and directly mothership patients.…”