A couple things to note;
Are you in the 56% coverage area or are you screwed if you have a stroke in a non coverage area?
I'm sure the definition of success in mechanical thrombectomy is not full recovery, it is just reperfusion. This is a perfect example of why stroke survivors are screwed. The goals are just lazy and wrong.
Skip the Turf Wars, Improve Endovascular Stroke Therapy Access?
The argument for training interventional cardiologists to work in the brain
Faced with a shortage of specialized
stroke neurologists in the U.S., some proposed that other
interventionists get extra training so they can step in and perform
endovascular stroke treatment in places that lack access to this
therapy.
"In rural areas and in small- to medium-sized communities without CSCs [comprehensive stroke centers] or 'stroke-ready' teams, skilled extracranial interventionists can play a critically important role in stroke intervention," according to David Holmes, Jr., MD, an interventional cardiologist at the Mayo Clinic in Rochester, Minnesota, and L. Nelson Hopkins, MD, a neurosurgeon at the University at Buffalo, New York.
There are only 800 to 1,100 neurointerventionalists across the country but nearly 10,000 interventional cardiologists, radiologists, and vascular surgeons who could expand future stroke teams, Holmes and Hopkins said in their review article published in the April 2 issue of the Journal of the American College of Cardiology (JACC).
"What is required is a willingness on the part of the neurointerventional community to train interested interventional cardiologists, radiologists, and vascular surgeons in stroke intervention, incorporate these interventionists into stroke teams, and make interdisciplinary collaboration the norm for this compelling public health issue," they emphasized.
Are The Skills Transferable?
Studies have shown that teams of neurologists and carotid stent-capable interventional cardiologists can together help acute stroke patients achieve outcomes that are not inferior to those from neurointerventionalists working at urban medical centers, as Christopher White, MD, an interventional cardiologist at Ochsner Medical Center, New Orleans, wrote in the same JACC issue.
A recent study also found that interventional radiologists learning from a neurointerventionalist achieved a technical success rate of 83% in their first 35 cases of mechanical thrombectomy.
"Interventional cardiologists, interventional radiologists, and interventional vascular surgeons must learn the basics of anatomy, pathophysiology, diagnosis of ELVO [emergent large vessel occlusion], neurotechnology, and methodology if they have interest in joining a stroke intervention team," Holmes and Hopkins cautioned.
But once the cerebrovascular skills are there -- for arterial vascular access, negotiating the aortic arch, and selective cannulation of the internal carotid artery -- it shouldn't be an issue whether the procedure is carotid stenting or mechanical thrombectomy of large vessel occlusion, White wrote.
Currently, these endovascular procedures are mostly being done by neurologists, neurosurgeons, and radiologists who follow certain standards in neuro-endovascular techniques in stroke intervention.
Interventional cardiologists may be able to perform these techniques, but it's "not a simple translation" from the cardiac blood vessels to brain blood vessels, argued Mitchell Elkind, MD, MPhil, a stroke neurologist at NewYork-Presbyterian Hospital in New York City.
In the last 5 to 10 years, more neurologists and neurosurgeons have joined the ranks of those who can perform these procedures as there are efforts to involve those who already have specific training in neurology, Elkind told MedPage Today. "Specialized training usually involves some training in neuro-critical care and stroke neurology, and then practical training in performing endovascular procedures under the mentorship of an experienced practitioner for at least 2 years."
White said he would agree with neuroradiologists who argue that they are the best at performing mechanical thrombectomy.
After all, endovascular volume does correlate with patient outcomes, as there is a greater 30-day mortality risk at low-volume facilities, a representative for the Society of NeuroInterventional Surgery pointed out when asked for comment.
"As conversations about providers of endovascular stroke therapy continue, it is important to note that nearly all of the cases enrolled in the ESCAPE and DAWN trials that demonstrated the benefit of thrombectomy were performed by formally trained neurointerventionalists who maintain high caseload volumes. We simply do not know if the research outcomes from ESCAPE and DAWN would be the same had the procedures been done by physicians without formal neurointerventional training and high caseload volumes," according to a statement from the group.
What Does This Mean for Access to Care?
The issue is access. Only 56% of the U.S. population could get to a CSC in under an hour by ground transport, according to a study from 2014.
"In rural areas and in small- to medium-sized communities without CSCs [comprehensive stroke centers] or 'stroke-ready' teams, skilled extracranial interventionists can play a critically important role in stroke intervention," according to David Holmes, Jr., MD, an interventional cardiologist at the Mayo Clinic in Rochester, Minnesota, and L. Nelson Hopkins, MD, a neurosurgeon at the University at Buffalo, New York.
There are only 800 to 1,100 neurointerventionalists across the country but nearly 10,000 interventional cardiologists, radiologists, and vascular surgeons who could expand future stroke teams, Holmes and Hopkins said in their review article published in the April 2 issue of the Journal of the American College of Cardiology (JACC).
"What is required is a willingness on the part of the neurointerventional community to train interested interventional cardiologists, radiologists, and vascular surgeons in stroke intervention, incorporate these interventionists into stroke teams, and make interdisciplinary collaboration the norm for this compelling public health issue," they emphasized.
Are The Skills Transferable?
Studies have shown that teams of neurologists and carotid stent-capable interventional cardiologists can together help acute stroke patients achieve outcomes that are not inferior to those from neurointerventionalists working at urban medical centers, as Christopher White, MD, an interventional cardiologist at Ochsner Medical Center, New Orleans, wrote in the same JACC issue.
A recent study also found that interventional radiologists learning from a neurointerventionalist achieved a technical success rate of 83% in their first 35 cases of mechanical thrombectomy.
"Interventional cardiologists, interventional radiologists, and interventional vascular surgeons must learn the basics of anatomy, pathophysiology, diagnosis of ELVO [emergent large vessel occlusion], neurotechnology, and methodology if they have interest in joining a stroke intervention team," Holmes and Hopkins cautioned.
But once the cerebrovascular skills are there -- for arterial vascular access, negotiating the aortic arch, and selective cannulation of the internal carotid artery -- it shouldn't be an issue whether the procedure is carotid stenting or mechanical thrombectomy of large vessel occlusion, White wrote.
Currently, these endovascular procedures are mostly being done by neurologists, neurosurgeons, and radiologists who follow certain standards in neuro-endovascular techniques in stroke intervention.
Interventional cardiologists may be able to perform these techniques, but it's "not a simple translation" from the cardiac blood vessels to brain blood vessels, argued Mitchell Elkind, MD, MPhil, a stroke neurologist at NewYork-Presbyterian Hospital in New York City.
In the last 5 to 10 years, more neurologists and neurosurgeons have joined the ranks of those who can perform these procedures as there are efforts to involve those who already have specific training in neurology, Elkind told MedPage Today. "Specialized training usually involves some training in neuro-critical care and stroke neurology, and then practical training in performing endovascular procedures under the mentorship of an experienced practitioner for at least 2 years."
White said he would agree with neuroradiologists who argue that they are the best at performing mechanical thrombectomy.
After all, endovascular volume does correlate with patient outcomes, as there is a greater 30-day mortality risk at low-volume facilities, a representative for the Society of NeuroInterventional Surgery pointed out when asked for comment.
"As conversations about providers of endovascular stroke therapy continue, it is important to note that nearly all of the cases enrolled in the ESCAPE and DAWN trials that demonstrated the benefit of thrombectomy were performed by formally trained neurointerventionalists who maintain high caseload volumes. We simply do not know if the research outcomes from ESCAPE and DAWN would be the same had the procedures been done by physicians without formal neurointerventional training and high caseload volumes," according to a statement from the group.
What Does This Mean for Access to Care?
The issue is access. Only 56% of the U.S. population could get to a CSC in under an hour by ground transport, according to a study from 2014.
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