Alongside his colleagues at the Barts Health NHS Trust, Levansri Makalanda (London, UK) was responsible for setting up the second ever 24/7 mechanical thrombectomy service for ischaemic stroke in the UK. He recently spoke to NeuroNews to outline how this service—which is still one of only a handful of 24/7 systems of its kind nationally—was established, and provide his views on the importance of round-the-clock thrombectomy access for patients.
In the UK, there is a significant disparity in access to thrombectomy services—particularly for deprived populations. In order to address this, we set out to establish a 24/7 thrombectomy service at the Royal London Hospital, which serves a particularly deprived part of East London. Our motivations for doing so were to improve access to life-saving treatment for patients in our local area, and to reduce the burden of stroke-related disability and death in our community.
Establishing a 24/7 thrombectomy service required a significant amount of planning and coordination. We worked closely with management, the stroke team, anaesthesia and the wider interventional radiology (IR) team—including nurses and radiographers—to develop a plan for the service. We started by setting up a seven-day service, and gradually built up the teams and resources needed to expand to a 24/7 service over the course of six months.
One of the main challenges we faced in maintaining the service was the COVID-19 pandemic, which put additional strain on staff. Additionally, within two months of establishing the 24/7 service, we were taking patients from throughout the south-east of England, from Peterborough to Margate. This vastly increased the number of patients we were treating, which required us to hire more staff to prevent burnout. However, finding the right staff was difficult, as all units were competing for these limited resources.
More generally, 24/7 mechanical thrombectomy services are important for a number of reasons. Firstly, they provide patients with timely access to life-saving treatments. Secondly, they reduce the burden of stroke-related disability and death in the community. This has knock-on financial effects on the National Health Service (NHS), but also for society as a whole.
In our own practice, we have seen the benefits of thrombectomy first hand, with patients making significant improvements in their neurological function after treatment and many being able to return to work. Whilst being the busiest unit to ever exist in the UK, our consultant-delivered service also has some of the best benchmarked outcomes for stroke thrombectomy.
As for the feasibility of a nationwide 24/7 thrombectomy service, it is likely that more services will be set up in the UK in the near future. Collaboration with partners and neighbouring units will be crucial in achieving this goal. Additionally, increasing the numbers of patients who qualify for thrombectomy will require more operators to be appropriately trained and employed. We believe that it is possible to achieve a nationwide service within the next few years—with the right resources and support.
Skilled operators and a robust stroke service are also key for setting up and maintaining a 24/7 offering; the major trials were all done in neuroscience units with trained neurointerventionists. If we fall below these standards, the outcomes are likely to suffer. This creates a number of challenges within a resource-strapped NHS system. While we are in the fortunate position of being able to attract consultants from across the world, given our pedigree in the field, the recruitment of properly trained neurointerventionists will be a problem in some parts of the UK, where there is already a shortage of doctors.
I believe—in order to maintain the great outcomes that we see in our service—patients will need to be transported to high-volume neuroscience centres for optimal management before, during and after the procedure. There is a lot more nuance than just pulling out a clot!
Looking to the future
We began this service with a view to constant iteration and improvement. We were down on neurointerventionist numbers—having four instead of the required eight—and also had only one room to operate in. These factors are being addressed as we speak. More junior doctors are further required within the stroke team, given the volume of referrals we receive, and we are looking to increase our bed base to help with the extra patients too.
In order to keep at the cutting edge, we are now also involved with a number of registries and trials so that we can contribute to the research and evidence base in the future while keeping at the cutting edge for the patients we currently treat. This has the added effect of allowing our thrombectomy stocks to be continually replenished, which is no mean feat during a worldwide polytetrafluoroethylene (PTFE) crisis.
In conclusion, 24/7 thrombectomy services are a vital component in the treatment of stroke. Our experience has shown that it is possible to establish a 24/7 service. It takes careful planning, coordination and collaboration but—with the right resources and support—a nationwide service can be achieved.
Levansri Makalanda is a consultant interventional and diagnostic neuroradiologist, and clinical lead for Interventional Neuroradiology, at Barts Health NHS Trust in London, UK. He is also a course director for the annual Barts Research and Advanced Interventional Neuroradiology (BRAIN) conference.