Teleproctoring in therapeutic neurointervention: Experience from Iraq-Saudi Arabia collaboration

Abstract

Background: Proctoring in neuroendovascular surgery is one of the potential solutions for the shortage of personnel and experience, particularly in unstable and limited-resource areas such as Iraq.

Methods: The study was conducted at the Baghdad Neurovascular Center (BNC), the first Hybrid neurovascular institution in Iraq, where sequential online zoom-based meetings between the BNC team and the expert from the Kingdom of Saudi Arabia were used for teleproctoring for neurointerventional procedures.

Results: A total of 28 sessions were conducted, four sessions for each case. Seven cases with various intracranial vascular lesions were operated for neuroendovascular procedures from July/2021 to March/2022. The teleproctoring for each case included four sequential sessions: (1) preoperative planning, (2) device selection and preparation, (3) intraoperative live-stream proctoring, and (4) postoperative reflection and follow-up planning. The procedures include coiling for dural arteriovenous fistula; preoperative tumor embolization; preoperative, partial, and staged embolization for arteriovenous malformation; coiling for intracranial aneurysm; and attempted Giant aneurysm flow-diversion. Major complications were avoided through teleproctoring, and all patients had good outcomes. In addition, the teleproctoring provided an effective training experience to the local neuroendovascular team that is otherwise not feasible.

Conclusion: Teleproctoring is an effective and feasible tool to improve patient outcomes and provide a training experience to the local neuroendovascular teams in resource-limited regions.

Keywords: Limited-resource area; Low- and middle-income countries; Medical Education; Neuroendovascular; Telemedicine; Teleproctoring.

Figure 1:

The setting, discussions, and view of the angio-screen during the teleproctoring procedure.

Figure 2:

Digital subtraction angiography of AP view of the right internal carotid artery showing the coil migration in a distal branch of the anterior cerebral artery (Red arrow). It also shows the complete obliteration of the arteriovenous malformation nidus. Note: The callosomarginal artery, in this case, is a segmented artery with the two segments originating separately from the pericallosal artery.

Figure 3:

The use of markers on angio-screen before injecting the embolizing agent into the feeders of arteriovenous malformation. Those markers represent a technical note from the proctor that serves early detection of the reflux by the operating team.