Innovations and challenges in interventional neuroradiology today

An ongoing conversation with Jacques Moret

This year is the 20th anniversary of the LINNC Paris Course, the distinctive “Live” case Course that has set the pace for the evolution in the practice of Interventional Neuroradiology.
LINNC online spoke with the founder of LINNC, Professor Jacques Moret, on his feelings during this special anniversary year – where we are, what will happen now – and how the profession of Interventional Neuroradiology can take the lead in public efforts to offer the best care for all patients…

Part 1

INNOVATIONS IN INTERVENTIONAL NEURORADIOLOGY AND THE IMPORTANCE OF MEETINGS LIKE LINNC PARIS AND LINNC SEMINARS

 

What are the innovations and challenges that you face today?

Jacques Moret at LINNC Paris

While several clinical trials over the last 2 years have vindicated the efficacy of the mechanical thrombectomy in relation to ischemic stroke, it is important to note that the whole field is in constant evolution.

On a very general level, courses like LINNC Paris and the different seminars in New York and Asia, allow participants to become acquainted with the large variety of devices that are available, for instance, stent retrievers. They then can see that it is very difficult to say that one is better than another, but rather, that they are all useful tools when chosen by an experienced practitioner…

Today, one of the critical questions is the nature of the clot itself…and whether we should capture a clot or suck the clot by aspiration. Innovative approaches to understanding the structure of the clot can help us in this decision-making process. One example is a recently developed tool (INSTENT) for capturing the identity of the clot on a wire. If we can give an electric identity to the cells of a clot, we could then create a recognizable clot cartography or histology…and while this is still at an animal study level, we may have some interesting results close to the end of the year.

In terms of AVMs, innovative emerging procedures are now recognized as very efficient such as the new precipitating hydrophobic liquid embolic agents: “ONYX” (Medtronic), “Squid” (Balt) or “PHIL” (Microvention).

Technically, in terms of material, we also have recently seen the introduction of devices having increased radiopacity using contrast agents as opposed to powder, which could avoid the danger of catheter occlusion…

 

“FOR THE ANEURYSM, TREATMENT TODAY OFFERS A DIVERSITY OF APPROACHES…”

The challenge of treating an aneurysm today is less complicated than it was 15 or 20 years ago because at that time we only had coils…
This does not change the challenge of the treatment, but now we have all kinds of tools that open the door to a wider treatment of aneurysms…depending on the patient and the morphology of the patient. This is a tremendous improvement.
We have coils, we have coils and stents, we have flow diverter stents where diversion of the flow is accomplished from inside the parent artery and we have others where diversion of the flow is from inside the pouch, the sac of the aneurysm, which is the WEB or the ARTISSE technology.

This newest technology, called an “endosaccular flow diversion device” (EFDD), is a kind of balloon made with a network-diverted flow, so you can induce thrombosis of the sac…. Approximately 2000 cases have now been performed worldwide and the results are promising…
Of course, you can mix an EFDD with a stent or a “toothpaste like material” (a precipitating liquid embolic agent), or you can use different approaches…which is definitely a plus…

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“WHY A “SEMINAR”?”

As you can see, the choices before us are immense – there is not a right or wrong device, but one that fits the indications and the operators’ skills. This is where courses like LINNC and the LINNC Seminars are critical. 

Every single device will be discussed in New York – including the newer devices like the WEB or the ARTISSE mentioned earlier… and here we will be able to see their use with multiple devices followed by in-depth and interactive discussions on them…

The excellent thing about the SEMINAR concept…is that if you have a problem, you can illustrate the problem with several cases, using different approaches and performed by different operators, but all dealing with the same problem. In this way, you can expose the issues that arise using a wide variety of the treatments available.

As these are pre-recorded cases in and under live conditions, nothing is missing because we record all imaging sources that are used during the treatment. Then, when the case is completed, we take the time to carefully process and edit the recorded “live” cases using the precise linkage offered by the time codes… In this way, we are sure that we are exposing the same elements at the same time from different angles.
We know exactly that, for instance, 5 of the 8 sources you need to illustrate the real problem occurred at a set of clearly recorded time codes and that these sources are exactly connected in time – very precise – that the images you see have been recorded at the same time…

It’s as if you were in the angio-suite yourself, but with several pairs of eyes…

 

The tremendous amount of work and preparation that goes in to these pre-recorded cases in advance of the Seminars offers an immense advantage for demonstrating a case or device or procedure.
The ability to synchronize the different aspects of the case may be a lot of work, but from a teaching point of view it is extremely useful because you can review specific points, you can rewind and look again and see the approach, review the case, show and discuss in real-time the complications

And this is a very important point: Of course we show the good treatment with the good indication and the good results, but we also show the good indication and the complications that arise during treatment…and then we can show the way you manage the complication – the way the complication was actually managed! 

Remember, this is something that cannot be done in a Live Course because, as you certainly know, during a live course, when we have a complication, we immediately stop the transmission and let the operator deal with the complication in a quiet environment… So we quit the case and leave them alone.
However, in a pre-recorded case, you also have the operator who can analyze the problem afterwards and how and why they approached it and solved it the way they did…which is extremely valuable, not only to the younger interventional neuroradiologists, but to all involved in the Seminar, no matter what their level of expertise.

So the Seminar, and the LINNC Paris Course, allow all the different aspects of our practice to come together, not only to introduce the new and existing technologies – but to offer the most complete introduction to the procedures themselves

> Watch our live and recorded cases!

 

…Read the second part of our conversation with Jacques Moret…

>>> PART 2: FUTURE PERSPECTIVES IN PROVIDING SOCIETY WITH THE RIGHT BRAIN TREATMENT

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