MECHANICAL THROMBECTOMY IN LATIN AMERICA

Santiago Ortega-Gutierrez, MD, MSc, FAHA, FSVINDirector of Neurointerventional Surgery in Neurology

Associate Director of Endovascular Surgery FellowshipAssociate Clinical Professor of Neurology, Neurosurgery and Radiology

University of Iowa

MT2020

MT2020 GLOBAL EXECUTIVE COMMITEE MEETING

LATIN AMERICA

• Heterogeneous ethnicities, societies, cultures.

• 20 countries

• Population: 642 million

• Stroke is 1º or 2º cause of death n most of the countries.

Silva, G.S., Maldonado, N.J., Mejia-Mantilla, J.H., Ortega-Gutierrez S et al.. Neuroemergencies in South America: How to Fill in the Gaps?. Neurocrit Care 31, 573–582 (2019)

CURRENT STATE OF STROKE CARE

• FRAGMENTED HEALTH CARE SYSTEM.• Centralized

• PUBLIC• Ministry of Health• Social security

• PRIVATE

• IV THROMBOLYSIS: still not well stablished

• MT: private settings.

NationalPlanfor

stroke

Acutestrokecare Rehabilitation

StrokeCentersStrokeUnits

Thrombolysis Thrombectomy In-hospital Afterdischarge

Accesstostrokecareandrehabilitation#

Argentina No 1public,5privatehospitals,nostroke

units

5privatehospitals 5privatehospitals Nodata Nodata Poor

Brazil Yes 156hospitals–50%

private,74with

strokeunits

78public,78

privatehospitals.

In24hospitals

thrombolisisisprovidedusing

telemedicine

64private,2public

hospitals

Widelyavailablein

strokeunits

Yes Intermediateaccess

toacutecare.Quick

accessto

rehabilitationafterdischargeislimited

Bolivia No Fewprivatehospitals,nostroke

units

Private Fewprivatehospitals Nodata Nodata Poor

Chile Yes 54hospitals,20

public,34private

hospitals,allwith

strokeunits

20public,34private

hospitalsincluding6

providing

thrombolysisusingtelemedicine

6public,6private

hospitals

Widelyavailablein

strokeunits

Yes Good

Colombia No 48hospitals,29%public,nostroke

units

14public,34privatehospitals

3Privatehospitals Yes Nodata Intermediateaccesstoacutecare,nodata

aboutrehabilitation

Ecuador No 1publichospital

withstrokeunit

1publichospital Not Only1

hospital

Nodata Poor

Paraguay No 2publichospitals

withstrokeunits,6

privatehospitals

withoutstroke

units

2public,6private

hospitals

Not Yes Nodata Pooraccesstoacute

care.Nodataabout

rehabilitationafter

discharge

Peru No 4publichospitals,1

withstrokeunit,1privatehospital

withoutstrokeunit

4public,1private

hospital

Not Nodata Nodata Pooraccesstoacute

care.Nodataaboutrehabilitation

Uruguay No 18hospitals,1

publicand1private

withstrokeunit,16

privatewithoutstrokeunits

18hospitals(1public,

17private)

1privatehospital Nodata Nodata Pooraccesstoacute

care.Nodataabout

rehabilitation

# Poor access - only few stroke centers in the country; Intermediate access - number of stroke centers is good but not enough according to the number of inhabitants or the number is good but the

country has some areas without coverage; Good access - Good number of centers according to the number of inhabitants and the centers are well distributed across the country.

WHO NCD Progress Monitor 2017Martins, Feigin V, et al, Lancet Neurology 2019

Priorities to reduce the burden of stroke in Latin American countries

Martins SO, Feigin V, et al, Lancet Neurology 2019 April

POPULATION HOSPITALS

GOVERNMENT EDUCATION

BARRIERS

• Lack of awareness

• Stroke is not a priority.

• Delays in arrivals, transfers.

• Not well stablished emergency transport.

• Poor established stroke policies: only in 2 countries. (Chile and Brasil)

• Most hospitals are not prepared for stroke care.

• Crowded public hospitals.

• Lack of 24/7: neurologists, CT scans, tPA, angiography rooms.

• Limited funding.• Limited

neurointerventional training.

KEY INITIATIVES: A parallel process

• Education• Population• EMS and ER• Neurology staff

• National Stroke Registry and protocols• Resilient

• Involvement of the government. Increase coverage for stroke care.• PAYMENTS ARE THE Key.

• Stroke awareness campaings: time limited impact

• Training the next generation of champions!

Costa Rica: CAMALEON strategy

TROMBOLISIS EN PERU

◦ LIMA

◦ PIURA

◦ CHICLAYO

◦ TRUJILLO

◦ ICA

◦ AREQUIPA

◦ CUSCO

◦ 3-12 por mes

◦ ESPORADICO

◦ (estudio BRIDGE)

Machline-Carrion MJ, Santucci EV, Damiani LP, et al. An international cluster-randomized quality improvement trial to increase the adherence to evidence-based therapies for acute ischemic stroke and transient ischemic attack patients: Rationale and design of the BRIDGE STROKE trial. Am Heart J 2019;207:49–57.

Randomization of EndoVascular Treatment with Stent-retriever and/or thromboaspiration vs. Best Medical Therapy in Acute Ischemic Stroke due to Large VEssel OcclusioN Trial (RESILIENT): Final Results of the

First Thrombectomy Trial in a Developing Country

Sheila Martins, Francisco Mont’Alverne, Octávio Marques Pontes Neto, Letícia Costa Rebello, Gisele Sampaio Silva, Fabrício Lima, Daniel Giansante Abud, Bruno de Sousa Mendes Parente, Michel Eli Frudit, Mário de Barros Faria, João José Freitas de Carvalho, Viviane

Flumignan Zetola, Leandro de Assis Barbosa, Fabrício Buchdid Cardoso, Ana Claudia de Souza, Leonardo Augusto Carbonera, JamaryOliveira Filho, Daniel Bezerra, David Liebeskind, Raul G Nogueira

Disability was significantly decreased in patients treated with MT(adjusted OR 2.3) with improved functional

independence at 90 days post stroke when compared to medical management alone (90-day mRS 0-2: 35% vs.

20%, NNT =6.6; adjusted OR 2.6)

JOIN mobile application

Real cases shared in real time

Quality indicators

CT and MRI DICOM viewer

Hospitals groups

Text message, audio or video call

KEY INITIATIVES: Training the new leaders!

• Education:• International rotations for neurology, neuro surgery residents at UI.

• Stroke conferences. Workshops with flow models (10 conferences).

• Surgical campaings and promotion of stroke care.

• International Neuroendovascular Fellowship program.

Angels LATAM

• Argentina, Chile, Peru, Colombia, Ecuador

• # Angels centers enrolled in Angels web page: 215

• #Stroke ready center: 106

• #Centers enrolled in Res-Q/SITs (Quality Monitoring): 55

•

• Mexico: 65 stroke ready center.

• Brazil: 180 hospitals

PLANS FOR THE FUTURE

• Involve the goverment. Policies for stroke care and coverage.

• Multidisciplinary team: neurologists, neurosugeons and neuroradiologist, nurses, EMS.

• Implementation of stroke units and centers.

• Telestroke.

• Increase neuroendovascular training opportunities.