But experts disagree on what constitutes the appropriate level of training and experience.
In a joint global position statement, the Society of Interventional Radiology (SIR), the Cardiovascular and Interventional Radiological Society of Europe (CIRSE), and the Interventional Radiology Society of Australasia (IRSA) have committed to providing necessary training to interventional radiologists in an effort to alleviate the shortage of physicians adept at endovascular stroke therapies.
The document was published online October 28, 2018, ahead of print in the Journal of Vascular and Interventional Radiology.
Its lead author, David Sacks, MD (The Reading Hospital and Medical Center, West Reading, PA), explained to Neurovascular Exchange via email that “members of SIR, CIRSE, and IRSA, as well as other IR societies, are already contributing to patient care, performing ischemic stroke thrombectomy. With the multitude of positive trials and the expanding indications for treatment, there is rapid growth in the number of patients treated and the number that could be treated but are not because of lack of access to care. The position statement will support IR physicians in seeking training for stroke interventions and being part of multispecialty teams in their hospitals.”
The position statement points out that the incidence of new strokes is 795,000 per year in the United States, of which 87% are ischemic.
Pivotal clinical trials have demonstrated that endovascular therapy in appropriate patients with large vessel occlusion acute ischemic stroke provides better outcomes than medical therapy alone. The approach has also been shown to be cost-effective.
The 2015 American Heart Association/American Stroke Association (AHA/ASA) guidelines reflect this reality, and based on the criteria they put forth, approximately 10 to 20 patients per 100,000 per year are eligible for endovascular therapy in the United States. Only a fraction of those patients receives this care, however, due to limitations of geography and the availability of appropriately-trained physicians.
In addition, with recent trials demonstrating the benefits of endovascular therapy that is delivered outside previously established windows of 4 to 6 hours following symptom onset, the AHA/ASA guidelines were updated in 2018. Now, the number of patients who are considered good candidates for endovascular therapy is expected to increase.
A Partnership for Future Care
“Increasing the number of appropriately-trained stroke interventional physicians will improve rapid access for patients,” according to Sacks. “The training includes extensive knowledge of stroke care and interventional tools and will be outlined in an upcoming revision of the 2009 SIR stroke training guidelines. Interventional radiologists may be available in locations where neurointerventional physicians are not available or may partner with neurointerventional colleagues to help provide 24 x 7 care. Patients may be able to avoid the delays that occur when they need to be transferred to distant hospitals for care.”
He expects that the newly-trained interventional radiologists can work in partnership with neurointerventionalists, as the latter “will continue to treat stroke but will have access to partners to share the demands of call and the need to sometimes treat simultaneous patients. IR partners bring competence in imaging, image-guided minimally invasive procedures, and clinical care. IR partners will also bring experience with IR tools and techniques that can help solve technical problems during a case.”
Disagreements Among Experts Persist
Sacks acknowledged, however, that there may be bumps in the road ahead, since the leadership of professional societies currently disagree on the role that interventional radiologists should play in stroke care.
“The consensus of the neurointerventional societies is that stroke interventions are best provided by physicians who have trained in dedicated neurointerventional fellowships,” he noted. “The consensus of the IR societies is that appropriately trained IR physicians can achieve outcomes comparable to neurointerventional physicians with the potential of decreasing time and increasing access to care.”
In the position statement, the authors note six case series from individual hospitals reveal outcomes of endovascular therapy performed by interventional radiologists that are comparable to those of international trials.
In a comment to NVX, Society for NeuroInterventional Surgery (SNIS) President Adam S. Arthur, MD (Semmes-Murphey, Memphis, TN), said that the group “welcomes the addition of more trained neurointerventionalists to our field. These physicians can come from different training backgrounds, and there are published standards for their training.”
He pointed out, however, that the position statement “asserts that neither fellowship training nor continued case volume are necessary for patients to be assured of good outcomes.
“Improving patient outcomes involves more than just learning how to use the equipment. It requires years of specialized training to address complex issues related to the brain and nervous system,” Arthur stressed. “Both formal fellowship training and continued case experience are critically important to ensure patients get the best possible care.”
Arthur referred to a 2017 literature review that references three studies showing poorer outcomes in lower volume stroke centers as well as a 2011 study showing a 1.9 greater odds of 30-day mortality in patients who were treated by low-volume facilities.
“Simply adding more physicians or certifying more stroke centers to tackle existing patient volume will not improve stroke care,” he emphasized to NVX. “We have to ensure that patients receive timely, appropriate care from highly trained physicians who treat a high volume of patients. The healthcare system has embraced this approach for trauma—transporting patients to a facility where the entire team has extensive training and experience. Do stroke patients deserve less?”
Sacks said he anticipates a future of cooperation. “We look forward to being partners with our neurointerventional colleagues. We believe that outcomes are the only credible measure of patient care for stroke and other interventions,” he concluded.
Source:
Sacks D, van Overhagen H, van Zwam WH, et al. The role of interventional radiologists in acute ischemic stroke interventions: A Joint position statement from the Society of Interventional Radiology, the Cardiovascular and Interventional Radiology Society of Europe, and the Interventional Radiology Society of Australasia. J Vasc Interv Radiol.. 2018;Epub ahead of print.
Disclosures:
Sacks and Arthur report no relevant conflicts of interest.
