"Le mélange des genres" - Mixing genres, Jacques Moret
In the Keynote Lecture, Jacques Moret argues that interventional cardiologists and interventional vascular radiologists have the ideal background, in terms of endovascular skill and training, to support interventional neuroradiologists in providing 24-hour cover for stroke patients who need mechanical thrombectomy of cerebral arteries. A highly sophisticated but rather dangerous procedure is beneficial for the patient, as long as the doctor is not more dangerous than the disease itself. Training and maintaining such skills requires appropriate education.
The Keynote Lecture provides an opportunity to reflect and absorb thought-provoking ideas. Whilst such prominence of a neuroradiologist at EuroPCR may at first glance seem slightly unusual, Jacques Moret has good reason to be present and opens a debate with significant relevance to the interventional cardiology community. He seizes this chance to consider the huge benefit that cerebrovascular accident (CVA) victims may now derive from state-of-the-art endovascular intervention and mechanical thrombectomy, but only if practised by appropriately trained operators. And that's the problem; how to increase the number of clinicians who are suitably trained in interventional neuroradiology, who also devote their time as intensively to CVA management as we expect our interventional cardiologists to spend managing myocardial ischaemia.
Jacques Moret laments the fact that in many European countries there are not enough interventional neuroradiologists to provide 24-hour cover for the whole population and, ‘There is a transitional period we have to think about.’ Most doctors, even in a busy hospital, will only deal with around 25 or 30 CVA victims a year, which will not give them the necessary experience to become interventional neuroradiologists quickly. Training sufficient numbers of doctors requires political support and, even with this, would come a considerable time lag. Neurosurgeons and neurologists who decide to follow a dedicated training programme and become full-time interventionists may offer a possible solution, but he reflects, "In modern stroke management there can be no place for a mechanical thrombectomy performed between two lumbar punctures".
So here is the key note. If we accept that the highly developed skills of interventional vascular radiologists and interventional cardiologists, who routinely operate outside the cerebral circulation, are in fact transferable, then there already exists a potential pool of experts who could help fill the void until the training of dedicated interventional neuroradiologists can catch up. Although Jacques Moret has identified this problem across Europe, he has already noted interest from clinicians around the world who share the view that, given the time constraints, this is the most responsible, ethical, route to follow while dedicated interventional neuroradiologists are being trained up.
Christoph Naber, an interventional cardiologist, is in agreement. "If interventional cardiologists, who undertake 24/7 myocardial infarction interventions, receive extra training then they offer the perfect setup to help patients." He recognises that in some countries neuroradiologists may need to learn to work with interventional cardiologists but "a patient-centred approach" should be the spirit in which we move forward, and that would naturally involve the expertise of interventional cardiologists.
Keynote Lecture: Tuesday 15th May, 11:56, Main Arena
Year of the textbook
"The PCR-EAPCI Percutaneous Interventional Cardiovascular Medicine Textbook is the successful realisation of the combined and constantly growing reflections, actions and experience of the entire ‘PCR Family’ and it will become the benchmark at the core of education for our community in the future." - Jean Marco, Chairman of PCR and Jean Fajadet, President EAPCI.
The result of a massive effort on the part of Europa Publishing comes to fruition this year as a new multimedia textbook linked to the PCR and EuroIntervention knowledge database is published. With contributions from over 250 authors, the resource will be available in print as four volumes and 2,200 pages, and also as web-based and iPad editions which will deliver multimedia content including over 200 videos.
However, collectors of dusty old masterpieces beware! This will be no static, frozen snapshot of knowledge which only reflects the opinion of a few at one point in time. The electronic versions truly bring the textbook to life. Reflecting the rapid advancement in techniques, devices and opinion, readers from all over the world are invited to criticise, question, qualify, improve and rephrase chapters - to take active ownership of an encyclopaedic, universal and unique piece of interventional wisdom.
This new resource is intended to become a core reference for interventional cardiologists in training across the globe and to set standards for certifying examinations.
20 years of radial access
An approach to the coronary arteries via the radial route was first described in the 1940s and was adapted for selective coronary angiography by Lucien Campeau in 1989. The technique was further modified in 1992 for coronary interventions by Ferdinand Kiemeneij.
Coronary angioplasty and stent implantation via the trans-femoral route presents conflicting challenges. Prevention of thrombosis within the coronary circulation is clearly important but because of the depth and size of the femoral artery, rapid coagulation in the groin is also important. This is a difficult balance to achieve and can be associated with significant complications, particularly as substantial haemorrhage deep within the groin can occur before clinical signs develop. It was this scenario that provided the motivation to seek an alternative and safer approach.
Being much smaller and more superficial, the radial artery provided an ideal alternative vessel. The approach is much more patient-friendly and cost-effective as the vessels in the forearm are easier to access and easier to compress than the deeper femoral artery and the patient can be mobilised soon after the procedure. However, operators had no experience of such an approach and it has taken time (20 years!) for familiarity and acceptance of this approach to evolve. Whilst it was quickly apparent that this new approach was associated with less bleeding, the evidence now demonstrates that mortality is also reduced, and this is particularly relevant to patients presenting with an acute coronary syndrome who require aggressive anticoagulant therapy. With such evidence now available, radial access has become more popular in the US, following its earlier adoption in Europe and Asia.
Dr Kiemeneij has seen his original technique evolve and gain acceptance across the globe but is still striving for improvement. “After 20 years of experience, we have robust evidence relating to the improved efficacy and safety benefit associated with this approach. However, we are also aware of the limitations of this technique in terms of vessel occlusion and need to invest in proper training to improve maintenance of radial artery patency.”