J Cerebrovasc Endovasc Neurosurg.  2022 Mar;24(1):24-35. 10.7461/jcen.2021.E2021.07.009.

The effectiveness of systemic and endovascular intra-arterial thrombectomy protocol for decreasing door-to-recanalization time duration

• Kim SC
• Lee CY
• Kim CH
• Sohn SI
• Hong JH
• Park H

• KMID: 2527592
• DOI: http://doi.org/10.7461/jcen.2021.E2021.07.009

Abstract

Objective
Variable treatment strategies and protocols have been applied to reduce time durations in the process of acute stroke management. The aim of this study is to investigate the effectiveness of our intra-arterial thrombectomy (IAT) protocol for decreasing door-to-recanalization time duration and improve successful recanalization.
Methods
A systemic and endovascular protocol included door-to-image, image-to-puncture and puncture-to-recanalization. We retrospectively analyzed the patients of pre- (Sep 2012–Apr 2014) and post-IAT protocol (May 2014–Jul 2018). Univariate analysis was used for the statistical significance according to variable factors (age, gender, the location of occluded vessel, successful recanalization TICI 2b-3). Independent t-test was used to compare the time duration.
Results
Among all 267 patients with acute stroke of anterior circulation, there were 50 and 217 patients with pre- and post-IAT protocol. Age, gender, and the location of occluded vessel have no statistical significance (p＞0.05). In pre- and post-IAT group, successful recanalization was 39 of 50 (78.0%) and 185/217 (85.3%), respectively (p＜0.05). Post-IAT (48.8%, 106/217) group had a higher tendency of good outcome than pre-IAT group (36.0%, 18/50) (p＞0.05). Pre- and post-IAT group showed 61.7±21.4 vs. 25±16.0 (p＜0.05), 102.0±29.8 vs. 82.7±30.4 (min) (p＜0.05), and 79.1±47.5 vs. 58.4±75.3 (p＜0.05) in three steps, respectively.
Conclusions
We suggest that the application of systemic and endovascular IAT protocols showed a significant time reduction for faster recanalization in patients with LVO. To build-up the well-designed IAT protocol through puncture-to-recanalization can be needed to decrease time duration and improve clinical outcome in recanalization therapy in acute stroke patients.

Keyword

Acute stroke; Anterior circulation; Intra-arterial mechanical thrombectomy; Protocol

Figure

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  Fig. 1. Schematic in-hospital workflow of patients with LVO from door to recanalization of the occluded vessel. LVO, large vessel occlusion.

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  Fig. 2. Flowchart of the standardized protocol from door to image to decrease time duration. In the entire protocol, the emphasis is that relevant stroke team (resident, staff, technician, and nurse) do their roles for patient preparation at the same time.

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  Fig. 3. The flowchart of the preparation of angio-suite on (angio-room door opening, angio-machine switch on etc.) in image-to-puncture; (A) In the pre-IAT period, the arrival of the technician makes the angio-suite on, (B) In the post-IAT period, whether doctor or angio-room technician first visit angioroom, angio-suite on can start, (C) Serial pictures with the order in which the angio-machine is operated (these files are placed on the desktop of angio-room computer, which is easily accessible to anyone who first visit.), (D) Sterile IAT kit including basic equipment for endovascular procedure such as syringes, 3-way check valves, flushing lines, 0.035 wire, and flushing lines, it can be especially helpful to decrease time duration in off-duty. IAT, intra-arterial mechanical thrombectomy.

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  Fig. 4. The flowchart of the preparation of all devices which is necessary for the IAT in puncture-to-recanalization; (A) In the pre-IAT period, from the femoral sheath to devices (stent or reperfusion catheter), no standardized protocol, (B) In the post-IAT period, through the whole procedure, standardized protocol is set for which instrument to use. IAT, intra-arterial mechanical thrombectomy.

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  Fig. 5. The flowchart of treatment modalities according to the location (proximal or distal) of occluded vessel in MCA occlusion. MCA, middle cerebral artery.

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  Fig. 6. The flowchart of treatment modalities according to the location (proximal or distal) of occluded vessel and the presence of CAS in ICA occlusion. CAS, carotid artery stenosis; ICA, internal carotid artery.

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