Direct to Angiosuite Versus Conventional Imaging in Suspected Large Vessel Occlusion: A Systemic Review and Meta-Analysis

Abstract

Background: There is growing evidence to suggest that the direct transfer to angiography suite (DTAS) approach for patients with suspected large vessel occlusion stroke potentially requiring mechanical thrombectomy shortens treatment times and improves outcomes compared with the direct transfer to conventional imaging (DTCI) model. Therefore, we conducted this meta-analysis to compare both approaches to build more concrete evidence to support this innovative treatment concept. Methods: All potentially relevant studies published in 4 electronic databases/search engines (PubMed, Web of Science, Cochrane Library, and Scopus) from inception to November 2021 were reviewed. Eligible studies were included if they enrolled ≥10 patients in both groups, were published in English, and reported baseline and procedural characteristics and outcomes. Relevant data were then extracted and analyzed. Results: Among 4514 searched studies, 7 qualified for the analysis with 1971 patients (DTAS=675, DTCI=1296). Times from door to puncture (mean difference, −30.76 minutes [95% CI, −43.70 to −17.82]; P <0.001) as well as door-to-reperfusion (mean difference=−33.24 minutes [95% CI, −51.82 to −14.66]; P <0.001) were significantly shorter and the rates of functional independence (modified Rankin Scale score, 0–2: risk ratio [RR], 1.25 [95% CI, 1.02–1.53]; P =0.03) at 90 days were higher in the DTAS versus the DTCI approach. There was no difference across the DTAS and DTCI groups in terms of the rates of successful reperfusion (modified Thrombolysis in Cerebral Infarction score 2B–3: RR, 1.03 [95% CI, 0.95–1.12]; P =0.42), near-complete/full reperfusion (modified Thrombolysis in Cerebral Infarction 2C–3: RR, 0.89 [95% CI, 0.74–1.08]; P =0.23), symptomatic intracranial hemorrhage (RR, 0.81 [95% CI, 0.56–1.17]; P =0.26), or fair outcomes (modified Rankin Scale score, 0–3: RR, 1.14 [95% CI, 0.88–1.47]; P =0.32) or mortality (RR, 0.98 [95% CI, 0.67–1.44]; P =0.93) at 90 days. Subgroup analysis showed no significant difference in 90-day functional independence across approaches in transfer patients (RR, 1.20 [95% CI, 0.96–1.51]; P =0.11). Conclusions: Our meta-analysis showed that the DTAS approach seems to be associated with improved time metrics and functional outcomes with comparable safety to the DTCI approach. Ongoing multicenter randomized clinical trials will hopefully provide more definite data about this promising approach.

Association of Time Course of Thrombectomy and Outcomes for Large Acute Ischemic Region: RESCUE-Japan LIMIT Sub-Analysis

“…Although controversial, the safety and efficacy of direct transfer to the angiography suite have been shown for patients with suspected large vessel occlusion stroke that may require EVT. 30-32 Our results indicate that time is critically important for patients with large cerebral infarction in the early time window, and this approach might be particularly effective in these patients.…”

Predictors of outcome after endovascular treatment for tandem occlusions: a single center retrospective analysis

“…However, this is far more complex in clinical practice. Though direct to angio suite may shorten the door to groin puncture time, functional outcome did not differ in patients transferred from a local stroke unit to an EVT center [ 27 ]. Schaeffer et.al.…”

Predictors for large vessel recanalization before stroke thrombectomy: the HALT score

“…This system, however, introduces potentially long time gaps between initial LVO diagnosis and EVT, during which a patient’s stroke may evolve, and the LVO may recanalize. Whether to repeat neuroimaging in patients transferred for EVT has been an area of active investigation, with most studies showing that DTAS without repeat imaging leads to shorter door-to-arteriotomy times and better clinical outcomes 7. However, whether DTAS is appropriate for all patients is unclear.…”

“…First, institutional protocols on repeating neuroimaging for patients transferred for EVT vary greatly. On the one hand, direct transfer to angiography suite (DTAS) without repeating neuroimaging has been shown to reduce time to EVT therapy and may be associated with improved outcomes7; on the other hand, bypassing neuroimaging may subject patients who had LVR before EVT to unnecessary invasive procedures. Thus, understanding factors that influence the likelihood of LVR may provide valuable guidance on whether DTAS or repeat imaging may be more appropriate for each patient.…”