Journal article
A Decade of Improvement in Door-to-Puncture Times for Mechanical Thrombectomy But Ongoing Stagnation in Prehospital Care
STROKE-VASCULAR AND INTERVENTIONAL NEUROLOGY, v 3(1), e000561
Jan 2023
Featured in Collection : UN Sustainable Development Goals @ Drexel
Abstract
Background: Systems of care surrounding endovascular therapy for stroke have garnered much attention in recent years. In-hospital metrics, such as door-to-puncture and procedure times have been areas for quality improvement. The temporal trend and clinical significance of prehospital onset-to-door time, however, remains unknown. Methods: We performed a systematic review of time metric data from all published randomized controlled and investigational device exemption trials involving endovascular therapy for stroke between 2005 and 2019 (n=26). Second, we conducted a record-level observational analysis on a total of 3512 patients from 3 real-world registries (Mechanical Embolus Removal in Cerebral Ischemia [MERCI], Thrombectomy REvascularization of Large Vessel Occlusions in Acute Ischemic Stroke [TREVO], and TREVO Stent-Retriever Acute Stroke [TRACK]), together with 4 prospective trials (MERCI trial, Multi-MERCI, TREVO-EU, and TREVO-2). Only patients receiving mechanical thrombectomy within 9 hours from onset-to-puncture time were included. Predictors of good outcome were identified using generalized linear mixed modeling. Results: Door-to-puncture times (slope=-5.83 min/y; R-2=0.25; P=0.046), procedure times (slope=-3.78 min/y; R-2=0.54; P<0.001), and onset-to-reperfusion times (slope=-11.82 min/y; R-2=0.57; P<0.001) improved over the years among previously published randomized controlled trials/investigational device exemption trials from 2005 to 2019. The prehospital metric of onset-to-door time, however, remained statistically unchanged (slope=1.03 min/y; R-2<0.01; P=0.806). Pooled analysis from record-level data demonstrated a similar temporal trend where door-to-puncture, procedure, and onset-to-reperfusion times declined by an average of 12 minutes (R-2=0.45; P<0.0001), 6 minutes (R-2=0.27; P<0.0001), and 8 minutes per year (R-2=0.18; P<0.0001), respectively, over a similar time period. Time from onset to door, however, did not improve (3.6 min/y; R-2=0.34; P=0.005). In a backward-selection regression model, onset-to-door time was found to be a significant predictor of patient outcomes, where every hour delay in hospital arrival correlated with a 14% reduction in the odds of a good outcome. Conclusions: Door-to-puncture and procedure times have seen significant improvements over the past decade. The prehospital component of onset-to-door time, however, has remained stagnant. This presents an unrealized opportunity to enhance patient outcomes through improved systems of care in the prehospital setting.
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Details
- Title
- A Decade of Improvement in Door-to-Puncture Times for Mechanical Thrombectomy But Ongoing Stagnation in Prehospital Care
- Publication Details
- STROKE-VASCULAR AND INTERVENTIONAL NEUROLOGY, v 3(1), e000561
- Publisher
- WILEY; HOBOKEN
- Grant note
- Clinical research was funded by Stryker Neurovascular. Manuscript was written under the direction of Drs Sun and Gupta. Patricia Morgan and Dr Jenkins fromStryker Neurovascular also reviewed and edited the manuscript for scientific accuracy. Although the sponsor was involved in the design, collection, analysis, interpretation, and fact checking of information, the content of this manuscript, the ultimate interpretation, and the decision to submit it for publication was made by the authors independently.
- Resource Type
- Journal article
- Language
- English
- Academic Unit
- Drexel University
- Web of Science ID
- WOS:001157345000006
- Other Identifier
- 991021860726304721
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- Collaboration types
- Domestic collaboration
- International collaboration
- Web of Science research areas
- Clinical Neurology
- Peripheral Vascular Disease