Johannes Kaesmacher MD, University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Bern, Switzerland

The medical field has historically developed a culture of perfectionism reacting slightly anaphylactic in response to failure. In contemporary endovascular stroke treatment, many scientific and organizational efforts focus on the optimization of workflows, extending the patient population eligible for therapy and maximizing the benefit achievable in each patient. However, systematic investigations on why endovascular procedures sometimes fail or become complicated are less common.

Only recently, two observational studies systematically evaluated reasons underlying complete reperfusion failures (Thrombolysis in Cerebral Infarction Score 0/1) in patients undergoing mechanical thrombectomy [1, 2]. The results of both studies were quite comparable, suggesting that the most common reason for reperfusion failure was failed removal of the thrombus, despite having established adequate intracranial access and having passed the intracranial thrombus. On the other hand, however, the analyses also put emphasis on less commonly encountered reasons, including failed extra- or intracranial access or difficulties passing the intracranial clot. While less common on its own, the aforementioned reasons in sum were as frequent as failed thrombus removal. Very occasionally, an active decision to stop the procedure for deemed futility or technical complications were causal for procedure termination and subsequent reperfusion failure. All of these reasons are well known by any interventionalist. Nevertheless, it continues to be important to classify the reasons and to provide exact numbers regarding their relative frequencies. Only then, will we be able to guide the interventional and device-manufacturing community in their priorities regarding new developments.

Besides an objective assessment of potential technical reasons underlying failed thrombectomy procedures, less emphasis is currently put on individual factors of the team in charge (interventionalist, anesthetists, neurologists) and other environmental influences. Although the physical and mental burden of interventional stroke treatment is well known[3, 4], no systematic evaluation takes into account team-centered, psychological and work-load factors so far. Before we fully comprehend the full dimension of reasons underlying failed endovascular stroke treatment procedures, we have to allocate data on this subject in a more systematic and detailed manner. Such allocation of data will in the future also have to include operator and physician-centered factors, such as personal perception of the case, shift-hours, overall workload, years of training, availability of supervision and/or technical support by nurses and many more.

“Success is not final, failures is not fatal: it is the courage to continue that counts.”  -unknown

References

  1. Leischner H, Flottmann F, Hanning U, et al (2018) Reasons for failed endovascular recanalization attempts in stroke patients. 1–5 . doi: 10.1136/neurintsurg-2018-014060
  2. Kaesmacher J, Gralla J, Mosimann PJ, et al (2018) Reasons for Reperfusion Failures in Stent-Retriever-Based Thrombectomy: Registry Analysis and Proposal of a Classification System. Am J Neuroradiol. doi: 10.3174/ajnr.A5759
  3. Williams MM, Wilson TA, Leslie-Mazwi T, et al (2018) The burden of neurothrombectomy call: a multicenter prospective study. J Neurointerv Surg 10:1143 LP-1148 . doi: 10.1136/neurintsurg-2018-013772
  4. Fargen KM, Hirsch JA (2018) Neurointerventionalists, stroke and burnout. J Neurointerv Surg 10:811 LP-812 . doi: 10.1136/neurintsurg-2018-014304