Intra-arterial therapy is currently applicable to a small subset of patients with ischemic stroke, but it will likely have an expanding role as new devices are introduced. This review evaluates the demand for such therapy and the physician work force available to provide such therapy in the United States. The available literature was reviewed to assess how many patients might need intra-arterial therapy annually and how many skilled neurointerventionalists are available to provide intra-arterial therapy for acute stroke. The number of acute ischemic strokes in the United States that will be amenable to intra-arterial therapy can only be crudely estimated, but it is certainly less than 126,000 per year and will quite likely be no more than 20,000 cases per year. The future demand for intra-arterial reperfusion techniques may change, but the number of patients who require intra-arterial thrombolysis is currently quite low. The overall number of neurointerventionists is currently adequate, though there might be local shortages.

http://www.ajnr.org/content/ajnr/30/3/453.full.pdf

Intra-Arterial Stroke Therapy: An Assessment of Demand and Available Work Force

Changing work practices and the evolution of more complex interventions in cardiovascular medicine are forcing a paradigm shift in the way doctors are trained. Implantable cardioverter defibrillator (ICD), transcatheter aortic valve implantation (TAVI), carotid artery stenting (CAS), and acute stroke intervention procedures are forcing these changes at a faster pace than in other disciplines. As a consequence, cardiovascular medicine has had to develop a sophisticated understanding of precisely what is meant by 'training' and 'skill'. An evolving conclusion is that procedure training on a virtual reality (VR) simulator presents a viable current solution. These simulations should characterize the important performance characteristics of procedural skill that have metrics derived and defined from, and then benchmarked to experienced operators (i.e. level of proficiency). Simulation training is optimal with metric-based feedback, particularly formative trainee error assessments, proximate to their performance. In prospective, randomized studies, learners who trained to a benchmarked proficiency level on the simulator performed significantly better than learners who were traditionally trained. In addition, cardiovascular medicine now has available the most sophisticated virtual reality simulators in medicine and these have been used for the roll-out of interventions such as CAS in the USA and globally with cardiovascular society and industry partnered training programmes. The Food and Drug Administration has advocated the use of VR simulation as part of the approval of new devices and the American Board of Internal Medicine has adopted simulation as part of its maintenance of certification. Simulation is rapidly becoming a mainstay of cardiovascular education, training, certification, and the safe adoption of new technology. If cardiovascular medicine is to continue to lead in the adoption and integration of simulation, then, it must take a proactive position in the development of metric-based simulation curriculum, adoption of proficiency benchmarking definitions, and then resolve to commit resources so as to continue to lead this revolution in physician training.

/pdf/the-future-of-simulation-technologies-for-complex-1sswbvr7dl.pdf

The future of simulation technologies for complex cardiovascular procedures

Introduction: Large vessel acute ischemic stroke has a poor outcome. Intravenous (IV) thrombolysis is often contra-indicated and if given, usually ineffective. Mechanical embolectomy is an option in these patients and may be performed by an interventional cardiologist experienced in carotid interventions. Method: Consecutive stroke patients were assessed by the stroke physician and, if eligible, referred for possible mechanical embolectomy using the Merci retriever. All procedures were done by a single cardiologist. Patient information, procedural characteristics and clinical outcomes at 90 days were collected by retrospective chart review. Results: A total of 22 patients were referred for emergency cerebral angiography with 17 undergoing mechanical embolectomy. The mean National Institute of Health Stroke Scale (NIHSS) score was 20.1 and the mean stroke duration was 284 min. Recanalization was successful in 15 (88%) patients. Ten patients (59%) had a good outcome (modified Rankin Score ≤2 at 90 days) and four died (mortality 23%). Three patients had significant intra-cerebral hemorrhage. There were no other major adverse events. Conclusions: For patients with large vessel occlusion strokes where IV thrombolysis was either contra-indicated or had failed, mechanical embolectomy performed by an interventional cardiologist had a high recanalization rate with an acceptable clinical outcome and safety profile. © 2010 Wiley-Liss, Inc.

Mechanical embolectomy for large vessel ischemic strokes: A cardiologist's experience

SNIS continues to develop and update practice guidelines for the delivery of NeuroInterventional care. This constant project represents a major societal undertaking. On occasion, it has bound our society to other medical groups. However, articulating what we believe to be “the correct” guidelines, at times places us at odds with others over critical issues. Why make this effort? Is it worth it?

In 2001, SNIS (then ASITN) published its first guidelines on NeuroInterventional therapies including aneurysms, arteriovenous malformations, head and neck tumors, epistaxis and acute ischemic stroke.1 2 3 4 5 6 7 8 These guidelines helped to define the “state-of-the-art” and served as a foundation for future clinical and technical advancement.

Other specialty societies as exampled by the American Society of Interventional Pain Physicians have embraced standards and guidelines and worked to involve their membership in the process by educating them in the method of evidence-based medicine (EBM).9 10 11 12 13 14 15

The Institute of Medicine defines clinical guidelines as “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances”.16 Such guidelines are statements developed and designed to assist both patient and provider in decision-making about the clinical circumstance that they may encounter. Where possible, clinical practice guidelines are statements of best practice that should be based on outcomes data of the treatments we employ.

In 1989, Congress mandated the creation of the Agency for Healthcare Policy and Research. This agency was given broad responsibility for supporting research, data development and related activities. At the same time, the National Academy of Sciences published a document indicating that guidelines are expected to enhance the quality, appropriateness, and effectiveness of healthcare services. While such conclusions might appear to be self-evident, one could argue that these goals have not been …

https://jnis.bmj.com/content/neurintsurg/early/2009/06/27/jnis.2009.000679.full.pdf

Technical standards and practice guidelines: should we? Why now? Why SNIS?

Acute Stroke Intervention

The primary therapeutic strategy for ischemic stroke, as for MI patients, is early reperfusion. Improvement in stroke treatment will require dedicated stroke centers to emulate MI quality indicators such as minimizing the "door-to-balloon time". A critical element in achieving this goal will be organizing the existing multidisciplinary pool of carotid interventionalists to provide the endovascular component of the acute care for ischemic stroke patients.

Interventional stroke therapy: current state of the art and needs assessment.

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Interventional stroke therapy: current state of the art and needs assessment.