Enhancing Education to Avoid Complications in Endovascular Treatment of Unruptured Intracranial Aneurysms: A Neurointerventionalist’s Perspective

Asking for Help

Neurointerventional skills are learned progressively, and a realistic and honest appraisal of one’s own skillset and limitations was considered crucial by most respondents. Fellows should know when to refer a case to a more experienced colleague and never be hesitant to reach out to colleagues for help and advice; not doing so means putting the patient at risk.

Many responses emphasized the importance of honestly discussing and revisiting complications and their management in an open and nonjudgmental environment,² be it in morbidity and mortality rounds,³ interaction with colleagues,⁴ or professional society meetings.

Treatment Indication

Ensuring successful treatment requires picking the right patients in the first place. Participants advised fellows to perform a thorough risk-benefit analysis before every treatment decision. Knowing which cases not to treat in the early years of practice was considered key knowledge for fellows.⁵ Proper review of noninvasive imaging to anticipate and prevent potential complications and planning of alternative strategies, “having a plan A, B, and C” as one of the respondents stated, was thought to be essential to handle unexpected events.

The goal is to ensure that patients receive the best possible treatment, be it endovascular, surgical, or conservative (“watch and wait”), and this will require an open and unbiased discussion among physicians from different medical specialties, including diagnostic and interventional neuroradiology, neurosurgery, and neurology.

Simulation Training and Standardized Procedural Steps

Simulation training constitutes a safe environment to practice technical skills.^6-10 Physicians believed that fellows should train as much as possible in a simulation environment to learn basic catheter skills before performing real cases. Standard operating procedures for every procedure step, close adherence to protocols for the management of intraprocedural complications, and choosing the simplest treatment approach possible were additional points physicians considered of high importance.¹¹

Safety

Using a few devices well was thought to be much wiser than the use of a wide variety of new devices, for which safety and efficacy data are often limited: “keeping it as simple and safe as possible,” as many of them put it. Accepting imperfection and avoiding unnecessary and dangerous perfectionist steps toward the end of a procedure were perceived crucial for fellows: “If you think that you can put one more coil, this is [the] time to stop.”

Humans make mistakes, and they make them frequently. Neurointervention is no exception to this rule, and the stakes are high. The advice summarized in this article (see the Figure for key recommendations for fellows and senior staff) is intended to help fellows and junior staff “to be wise” as Roy H. Williams put it—that is, to learn from the mistakes of their more experienced colleagues.