Background and Objective:
Recent RCTs have failed to show benefit of intra-arterial therapy (IAT). We sought to determine whether these trials have affected the views and practice of IAT amongst stroke-treating physicians.
Methods:
An international web-based survey was sent to 753 stroke-treating physicians across the globe.
Results:
322 physicians responded (43% rate); 25% were interventionalists; 80% practice in 24/7 IAT capable centers (fig 1). IAT volume per year prior to the RCTs (fig 2) has now decreased according to nearly half of the respondents. Physicians are now more selective (59%) while a third made no changes in pursuing IAT and 6% “do not pursue IAT anymore” (fig 3). Although 76% still perceive IAT is effective under certain criteria, two thirds said they feel “less obligated” to offer IAT. When asked about the RCTs, respondents felt the devices were outdated (36%), patient selection methods were “not optimal” (32%), recanalization rates could have been better (25%) or the trials should have been better designed (20%). Interestingly, centers currently enrolling in IAT trials intervene on large proportions of patients outside of studies (fig 4). The single most important factor in patient selection is shown in fig 5. Over half prefer a CT modality for patient selection; while 16% chose MRI and 11% use clinical criteria only when deciding to pursue IAT. Finally, three quarters of the contributors said that patients should be taken to IAT only in the context of clinical trials to test its efficacy, 21% said IAT should be continued “outside of trials” and only 3% pronounced it not useful (fig 6).
Conclusion:
While the results of recent RCTs have changed the views of stroke treating physicians, IAT continues to be practiced worldwide. The majority of our respondents is more selective and awaits results of new trials with the stent retrievers and better selection methods. Despite endorsing the practice of IAT only within trials, over half are still treating cases outside studies.
Explaining clinical study designs to patients
