Direct Transfer to Angiosuite Triage Strategy for Patients Undergoing Mechanical Thrombectomy in a Rural Setting

Abstract

Background A direct admission to angiosuite (DAA) strategy in transfer patients with large vessel occlusion (LVO) is considered to decrease stroke time metrics and benefit functional outcomes. However, feasibility and effectiveness of DAA have not been established in rural settings. Fast door‐to‐reperfusion times and high‐quality reperfusion are key predictors of outcome in patients with LVO. To reduce treatment times in transferred patients with suspected LVO, we initiated a DAA triage protocol in 2017. Methods We conducted a nested interventional cohort study of adult patients with anterior LVO from January 2015 to August 2019 transferred to our center from an outside hospital. Patients were divided into DAA for mechanical thrombectomy (MT) and patients directly admitted to the emergency department (DAED). DAED was subdivided into patients undergoing MT and patients who did not. Workflow times and clinical and radiographic outcomes were analyzed. Results Forty‐five DAA patients and 241 DAED patients (DAED patients undergoing MT=134 patients and DAED patients not undergoing MT=107 patients) were identified. DAA patients had significantly shorter median door‐to‐arterial‐puncture times (15 versus 71 minutes) and puncture‐to‐recanalization times (27 versus 42.5 minutes). At discharge, DAA patients had a significant decrease in median admission National Institutes of Health Stroke Scale (NIHSS) score (ΔNIHSS score 10 versus 4; P =0.02), and higher rate of dramatic clinical improvement (ΔNIHSS score >10; 48.9% versus 23.5%; P <0.001). Both groups had comparable rates of functional independence (modified Rankin Scale; mRS 0–2; 36.1% versus 29.2%; P =0.52), and mortality at 90 days ( P =0.63). When mortality was excluded, DAA patients showed a significant proportion of excellent functional outcome (mRS 0–1; 50% versus 26%) before ( P =0.04) and after ( P =0.02) adjusting for confounders. Conclusions DAA is feasible and can safely reduce reperfusion times in transferred patients with LVO to MT centers in a rural setting. Reducing workflow times may impact the functional recovery of patients undergoing MT.