Direct Transfer to Angiosuite Triage Strategy for Patients Undergoing Mechanical Thrombectomy in a Rural Setting

Abstract

Background A direct admission to angiosuite (DAA) strategy in transfer patients with large vessel occlusion (LVO) is considered to decrease stroke time metrics and benefit functional outcomes. However, feasibility and effectiveness of DAA have not been established in rural settings. Fast door‐to‐reperfusion times and high‐quality reperfusion are key predictors of outcome in patients with LVO. To reduce treatment times in transferred patients with suspected LVO, we initiated a DAA triage protocol in 2017. Methods We conducted a nested interventional cohort study of adult patients with anterior LVO from January 2015 to August 2019 transferred to our center from an outside hospital. Patients were divided into DAA for mechanical thrombectomy (MT) and patients directly admitted to the emergency department (DAED). DAED was subdivided into patients undergoing MT and patients who did not. Workflow times and clinical and radiographic outcomes were analyzed. Results Forty‐five DAA patients and 241 DAED patients (DAED patients undergoing MT=134 patients and DAED patients not undergoing MT=107 patients) were identified. DAA patients had significantly shorter median door‐to‐arterial‐puncture times (15 versus 71 minutes) and puncture‐to‐recanalization times (27 versus 42.5 minutes). At discharge, DAA patients had a significant decrease in median admission National Institutes of Health Stroke Scale (NIHSS) score (ΔNIHSS score 10 versus 4; P =0.02), and higher rate of dramatic clinical improvement (ΔNIHSS score >10; 48.9% versus 23.5%; P <0.001). Both groups had comparable rates of functional independence (modified Rankin Scale; mRS 0–2; 36.1% versus 29.2%; P =0.52), and mortality at 90 days ( P =0.63). When mortality was excluded, DAA patients showed a significant proportion of excellent functional outcome (mRS 0–1; 50% versus 26%) before ( P =0.04) and after ( P =0.02) adjusting for confounders. Conclusions DAA is feasible and can safely reduce reperfusion times in transferred patients with LVO to MT centers in a rural setting. Reducing workflow times may impact the functional recovery of patients undergoing MT.

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

“…A total of 12 studies20–31 were included in the systematic review. From those, due to population overlap, only eight24–31 were included in the meta-analysis.…”

“…A total of 12 studies20–31 were included in the systematic review. From those, due to population overlap, only eight24–31 were included in the meta-analysis. One single cohort study27 presented overlap with a clinical trial29 and a multicenter observational study30 as well.…”

Angiography suite cone‐beam CT perfusion for selection of thrombectomy patients: A pilot study

“…Moreover, a recent study using flat panel noncontrast CT in AIS‐LVO early window patients observed reduced reperfusion times and improved functional outcomes 10 . With the ability to obtain perfusion images in the angiography suite, potential AIS‐LVO late window patients may bypass the multidetector CT, thereby decreasing the workflow times of hospital arrival to recanalization 7–9,25 . In our previous study, we showed that direct admission to angiosuite for early window patients transferred to our center can reduce reperfusion times by a median of 73 minutes in comparison to patients directly admitted to the emergency department 26 .…”

“…10 With the ability to obtain perfusion images in the angiography suite, potential AIS-LVO late window patients may bypass the multidetector CT, thereby decreasing the workflow times of hospital arrival to recanalization. [7][8][9]25 In our previous study, we showed that direct admission to angiosuite for early window patients transferred to our center can reduce reperfusion times by a median of 73 minutes in comparison to patients directly admitted to the emergency department. 26 These results in conjunction to the shorter acquisition times (less than a minute), and postprocessing software to estimate accurate perfusion volumes on CBCTP 27…”

“…[7][8][9]25 In our previous study, we showed that direct admission to angiosuite for early window patients transferred to our center can reduce reperfusion times by a median of 73 minutes in comparison to patients directly admitted to the emergency department. 26 These results in conjunction to the shorter acquisition times (less than a minute), and postprocessing software to estimate accurate perfusion volumes on CBCTP 27…”