MECHANICAL THROMBECTOMY IN LATIN AMERICA · Angels LATAM •Argentina, Chile, Peru, Colombia,...
Transcript of MECHANICAL THROMBECTOMY IN LATIN AMERICA · Angels LATAM •Argentina, Chile, Peru, Colombia,...
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.