To Master Stroke Thrombectomy, It Takes Way More Than 50 Cases

 You better be prepared to interview your doctor and see if they pass the interview and are OK to be hired. YOUR RESPONSIBILITY!. You can't trust your stroke hospital to vet their doctors. They have allowed complete and total failure in all aspects of stroke.

To Master Stroke Thrombectomy, It Takes Way More Than 50 Cases

 

Competency a "touchy subject" for training programs, trainees, and new graduates

by Nicole Lou, Staff Writer, MedPage Today July 9, 2021

The learning curve in endovascular therapy (EVT) remained steep even after operators passed training and reached autonomy, one group found.

At seven French centers, established interventional neuroradiologists showed continued improvement in certain performance metrics as they accrued mechanical thrombectomy experience:

• Procedural time: increasing individual experience was independently associated with shorter procedure durations

• Recanalization status: increasing experience was independently associated with better Thrombolysis in Cerebral Infarction scores

• First-pass recanalization: there was no effect of operator experience on first-pass complete reperfusion

• Complications: operator experience made no difference in the rates of perforation or arterial dissection

Operators appeared to continue honing their skills up to around their 80th to 100th procedure outside training, reported Grégoire Boulouis, MD, PhD, of Université de Tours, and collaborators. Their paper was published online in Stroke.

For comparison, the investigators said, most training guidelines recommend that trainees undergo approximately 50 EVT procedures as a first operator before operating autonomously.

"This raises questions for designing training programs. It is a touchy subject that is often avoided," noted the authors of an accompanying editorial.

"The problem with experience is that it takes time to get it. Newly independent interventionalists can only get more experience by doing cases. Eighty cases are a large number that will take years to accumulate," wrote Shelagh Coutts, MD, of the University of Calgary Cumming School of Medicine in Alberta, and Diogo Haussen, MD, of Emory University School of Medicine and Grady Memorial Hospital in Atlanta. They cited an unpublished estimate that U.S. operators performed fewer than 12 stroke thrombectomies on average in 2016.

Even so, it is "reassuring" that the thrombectomy learning curve appeared to be volume-based and not time-based, "suggesting trainees and recent graduates can achieve a steeper learning curve by being exposed to larger procedure volumes," said Amrou Sarraj, MD, of UTHealth McGovern Medical School in Houston, who was not involved with the study.

He suggested that procedure volumes can be expected to increase as evidence grows and indications expand. "If this gain is directed towards increased exposure to trainees, this would have a significant beneficial effect on their skill levels," he told MedPage Today.

Furthermore, if there is a true minimum number of cases that needed to be completed before a operator can gain autonomy in EVT, it may not necessarily be 50, 80, or 100.

"Endovascular therapy for acute stroke, as any other procedure, has and will continue to mature and evolve over time, and the volume-outcome relationship may change with new technologies and approaches," Coutts and Haussen said.

Boulouis and colleagues performed a retrospective analysis of individual thrombectomy procedural data for 36 operators. The cohort had performed 4,516 procedures altogether from January 2015 to January 2020; after exclusions, 4,012 procedures with sufficient operator data were included in the analysis (median 97.5 per operator).

Operator experience was defined as the total number of stroke thrombectomies performed since 2015 -- the year EVT officially proved to be a game changer in acute ischemic stroke, thanks to the MR CLEAN, SWIFT PRIME, and REVASCAT trials.

The study's retrospective design was a major limitation that left room for confounding. Also, many of the participating centers had performed thrombectomies well before 2015 that were not counted by Boulouis' group.

"This is a powerful study that, despite some design limitations, demonstrates the importance of expertise in driving stroke thrombectomy outcomes. Expertise has been validated across a wide variety of surgical procedures, and it is not surprising that it is likewise important in stroke surgery," commented J Mocco, MD, MS, of Mount Sinai Health System in New York City, who was also not involved with the study.

"Stroke thrombectomy is an extremely technical procedure and the quality of outcome makes a tremendous impact for the patient. While there is still work to be done, this paper provides additional clear evidence that expertise matters and should be taken into account when designing stroke systems of care," he told MedPage Today.

• 

  Nicole Lou is a reporter for MedPage Today, where she covers cardiology news and other developments in medicine. Follow

Disclosures

Boulouis had no disclosures; a co-author reported grants from Microvention, Stryker Neurovascular, and Penumbra.

Coutts had no disclosures; Haussen disclosed relationships with Stryker, Cerenovus, Vesalio, and Viz.AI.

Saraj and Mocco noted no disclosures in relation to their comments.

Primary Source

Stroke

Source Reference: Zhu F, et al "Effect of operator's experience on proficiency in mechanical thrombectomy: a multicenter study" Stroke 2021; DOI: 10.1161/STROKEAHA.120.031940.

Secondary Source

Stroke

Source Reference: Coutts SB, Haussen DC "When more is better..." Stroke 2021; DOI: 10.1161/STROKEAHA.121.035303.

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