Key clinical point: Higher volume matters for achieving good outcomes in acute ischemic stroke patients undergoing endovascular thrombectomy.
Major finding: Minimum volumes for a higher rate of good outcomes was 29 cases/year per center, and 19 cases/year per proceduralist.
Study details: An analysis of 13,311 Medicare patients who underwent endovascular thrombectomy for an acute ischemic stroke during 2016 and 2017.
Disclosures: Dr. Stein had no disclosures.
Stein LK et al. ISC 2020, Abstract LB11.
The results reported by Dr. Stein raise issues about balancing the access to certain therapies with the outcomes of those therapies. Having procedures like endovascular thrombectomy for acute ischemic stroke done primarily at high-volume centers might improve procedural outcomes, but having more centers offering this treatment across wider geographical areas would make this treatment more broadly available to more people.
Treatment for acute ischemic stroke also involves the very important element of time that also affects the balance between access and outcomes. Unlike more elective endovascular procedures, like transcatheter aortic valve replacement, patients with an acute stroke need treatment suddenly and quickly. Many stroke patients can’t take the time to travel to a regional referral center. Ideally, they need treatment somewhere they can arrive within minutes of their stroke onset. When a study assesses the outcomes of stroke patients treated with thrombectomy and relates that to case volume, an important parameter that’s not addressed is the number of acute ischemic stroke patients who didn’t receive optimal treatment because they arrived at a center that offers thrombectomy too late. It’s not necessarily bad to have a lower-volume center treat stroke patients in a timely manner if the alternative is to have patients spend substantially more time traveling to a high-volume center.
For endovascular thrombectomy, center volume and experience may be much more important than proceduralist volume because having a smoothly functioning system in place is so important for rapid stroke assessment and treatment. It’s also important for programs to provide experienced and comprehensive postthrombectomy care. Success in endovascular thrombectomy involves much more than just taking a clot out. It means quickly and smoothly moving patients through the steps that precede thrombectomy and then following the intervention with a range of services that optimize recovery.
Ashutosh P. Jadhav, MD, PhD , is director of the comprehensive stroke center at the University of Pittsburgh. He had no relevant disclosures. He made these comments in an interview.