The “HIS and HER Cart”—Solution to Pandora's Box in Acute Ischemic Stroke Intervention
Correspondence Address: Source of Support: None, Conflict of Interest: None DOI: 10.4103/0028-3886.304123
Source of Support: None, Conflict of Interest: None
“Great things are not done by impulse, but by a series of small things brought together”
Vincent Van Gogh
Endovascular treatment has become standard of care in acute ischemic stroke with proximal large vessel occlusions. Key to the success is the concept of “Time is brain” and in this case recanalization as fast as possible.
Most of the emergency calls of acute stroke happen during odd hours or on holidays. Ordering emergency imaging, obtaining informed consent, and organizing allied technical staff for the procedure including anesthesia takes its own time. In Indian set up, the additional financial burden on the patient's family is huge and expectations are very high and hence achieving the goal of fast recanalization requires dedicated teamwork and pre-organization of the entire setup.
Hence, all efforts should be made to reduce the door to recanalization time by facilitating this process. One important step toward achieving this is to have “ready to go hyperacute ischemic stroke (HIS) and handy endovascular retrieval (HER) cart” [Figure 1] in the catheterization (cath) lab. Various consensus guidelines have already spoken about the need to have a recanalization kit ready in the cath lab.,Some institutions even prefer to keep all necessary hardware opened and ready for use except for stent.
The additional modifiable challenge here is the pre-organization of the required materials since the cath lab is often common for cardiologists, general radiology, and vascular surgeons. Hence, dedicated materials required for mechanical thrombectomy may not be readily available. This can be overcome by HIS and HER cart.
The cart basically contains all the necessary materials stored in one box with a trolley. All diagnostic catheters, guiding catheters, and long sheaths are in open vertical storage at the back and necessary microcatheters, microwires, stent retrievers, aspiration tubes, Y connectors, snares, and emergency coils are in the main closed central compartments. While a patient is being draped, the interventionist can review images, analyze vascular anatomy and have a mental roadmap for catheter access specific to that patient thereby asking staff to pull out those catheters and be ready by the time a puncture is being made.
This is similar to the STEMI box to shorten door to balloon time in cardiology lab which has been proven effective to save time in an emergency. The cart can be custom made similar to the one shown in the picture below made up of tough polycarbonate body with wheels. This can be rolled around various cath labs in the hospital in big setups with multiple sites of stroke intervention.
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Among author contributions in the cover letter, the following acknowledgement was given.
Dr Venkatesh Aiyagari,
University of Texas Southwestern Medical Center.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.