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An Overview of Mission Thrombectomy 2020+
In this installment of Expert Conversations, Neurology Learning Network Stroke and Vascular Section Editor, Amrou Sarraj, MD, professor of neurology at Case Western Reserve University - Stroke Division Chief, Stroke System Director at University Hospitals Neurological Institute, sits down with Dileep R. Yavagal, MD, FAHA, FAAN, FSVIN, Director of Interventional Neurology and Co-Director of Neuroendovascular Surgery at the University of Miami & Jackson Memorial Hospitals and Clinical Professor of Neurology and Neurosurgery at the University of Miami Miller School of Medicine, to discuss Mission Thrombectomy (MT) 2020+.
May 15, 2022, marks the second annual World Thrombectomy Day initiated by MT 2020+. Listen here as Dr Yavagal discusses the journey of success and the important next steps of MT 2020+.
Read the transcript:
Amrou Sarraj, MD: Greetings. This is Amrou Sarraj, I'm a professor of neurology at Case Western Reserve University and the Vascular Section Editor at Neurology Learning Network. And in this podcast, it's my great pleasure to welcome Dr. Dileep Yavagal, the professor of neurology and neurosurgery and the co-director of intervascular neurosurgery at University of Miami, Miller School of Medicine. Who will talk to us about an impressive and really refreshing movement that he has been leading for the last few years in Mission Thrombectomy 2020+. So thank you, Dr. Yavagal, for giving the time and talking to us about this very important endeavor.
Dileep Yavagal, MD: Amrou, thank you so much for inviting me. And it's a real pleasure to be here.
Dr Sarraj: Wonderful. Well, our audience in neurology and stroke and other aspects who care about advancing patients' care and disseminating effective treatments and tackling disparities would be eager to hear from you, what is Mission Thrombectomy 2020+? How did it start? What was the inspiration behind it? So please go ahead and tell us.
Dr Yavagal: Absolutely, absolutely. So Mission Thrombectomy 2020+ is a global peer network at its very core. Where stroke and interventional neurologists, interventional radiologists, neuro-endovascular neurosurgeons around the globe have joined together to pursue a singular mission to accelerate access to stroke thrombectomy globally. This is fairly unique in the sense that there isn't as large a global stroke campaign that has been done yet. We are up to more than 400 peers that have joined together to pursue this mission. The inspiration really came from the Florida stroke registry that my chairman, Dr Ralph Sacco, was funded for by the [National Institutes of Health], and then the Florida state government continued funding.
And I'm on the endovascular committee and really saw the power of public health approaches and specifically public health interventions in increasing access to stroke care and increasing the quality of stroke care with public health approaches. So I really saw the possibilities from that campaign that could be applied globally. And in 2016, proposed this to the SVIN board and was very grateful that they allowed me to go forward with something that has not been done really, not just by SVIN, but even by other bigger societies or one where we aim to have a multicountry, multicontinent campaign to focus on thrombectomy. So, this was done in 2016 and the campaign was launched at the SVIN meeting that year.
When one looks at the global epidemiology of stroke, the latest global burden of disease survey tells us that there are 13 million strokes per year globally. And even if one took 10% of those as a conservative estimate of large vessel occlusions, we are looking at 1.3 million large vessel occlusions per year. And if we see the number of thrombectomies that are being done, especially in 2016 when we started, the number of thrombectomies around the globe was less than a hundred thousand, it was just about 70,000 or so. So, the gap in the patients who need stroke thrombectomy, approximately 1.3 million, and the number of thrombectomies that were done, that were less than 5%, is really something that was appalling to me. And personally, having been part of the revolution and seeing the amazing results, this felt that something that needed to be addressed. So certainly, that was a big motivation to form this global movement.
Dr Sarraj: Well, that's wonderful. And thank you for championing this and supporting it and starting it from the beginning. And it would be very good to hear about the goals and the mission that you sat with your colleagues on the start of the campaign and how it's evolved over time.
Dr Yavagal: Absolutely. The major mission and vision and goals were essentially 5. We aimed to integrate the knowledge of barriers to thrombectomy that are present in countries throughout the world, and really coalesce that knowledge as peers together. For example, knowledge of LVO triage amongst nonneurology colleagues such as [emergency room] doctors. Barriers of reimbursement, barriers of prehospital recognition of LVO stroke, large vessel occlusion stroke in the field. These are barriers that are common around the globe and are tackled in different manners. And we aimed in our first goal to integrate that knowledge and share the best practices around overcoming these barriers in the campaign. Secondly, we aimed to really be an umbrella campaign that would unify multiple efforts that are always ongoing by local stroke and interventional societies, as well as national societies in different countries, and join hands with these efforts so that there could be a synergy that could be brought upon this endeavor.
And we felt that the global nature of this campaign would lend a beneficial effect to the local and national societies, and they could in return lend back lessons that the global community could share. So that was a second goal, to unify multiple efforts. And the third effort, which I would say is unique for any campaign like ours, is that we wanted to develop and implement high-impact public health interventions to achieve our goal. And this is very important, and I had to educate myself on this approach, but it's well established and very powerful, where one uses a top-down approach that impacts the economics, that impacts the policy making, and that impacts public level education to achieve your access to treatment goals. So, instead of going from hospital to hospital building centers, which is a grassroots approach, public health interventions are top down and have the capacity to influence a large region in access to treatment.
So, developing and implementing high-impact public health interventions in a given region by the regional committees was the third goal. And the fourth goal was to make sure that all these efforts truly result in a defined metric of acceleration, and that we defined as doubling of thrombectomy numbers in each region every 2 years. This was certainly somewhat random, but on the other hand, if a region does 10 thrombectomies, then in 2 years, they have to get to 20. If a region did 500 thrombectomies, they had to get to a thousand. And so we, for the simplicity aspect, we chose this metric. And with these 4 goals, we set a milestone in 2016, that in 2020 we would reach a goal of 202,000 thrombectomies, which was certainly a catchy number for 2020, but also it provided the doubling from 2016 to 2018 and then 2018 to 2020.
So those were really the goals we set out for ourselves. And they have, I have to say with a lot of satisfaction, evolved very positively. And I can certainly elaborate on each of those, we have actually met the goal of 202,000 thrombectomies. There was actually 205,000 thrombectomies officially done globally in 2020. Certainly we don't take full credit for that, but we certainly had close to 80 regional committees working towards that goal for several years, that probably contributed at least somewhat to the achievement of that goal. And I can tell you examples of public health interventions around our 90 regional committees and 90 regions that have been showing a lot of impact in those regions for accelerating thrombectomy.
Dr Sarraj: That's wonderful, congratulations on not just the ambitious goals, but on achieving them. That is really satisfying to say the least.
Dr Yavagal: Thank you.
Dr Sarraj: And you alluded in your answer to regional committees and apparently a movement like this that goes in multiple continents. Must have a certain structure that allows the execution to go across globe. So, please tell us a little bit about that structure.
Dr Yavagal:
Absolutely, Amrou. So we organized the campaign with a horizontal structure and with an analogy to the stroke field, like a spoke and hub structure. We have a core executive committee that is the hub that's located in the US, and the spokes are regional committees that are located in each country, and sometimes there are multiple regional committees in a given country given the size of the country. And these regional committees are truly the heart and soul and the functioning engines of MT 2020+. They are composed of a stroke leader as a co-chair in that region, a neurointerventional leader as a second co-chair, and then 6 to 8 stroke and neurointerventional leaders in that region. But it also includes, if possible, a community member interested in stroke, and also a policy maker that could be included.And we are very proud that in Georgia, the wise health minister joined the committee as a policymaker, joined the committee. So these regional committees meet either on a monthly or a once in 2-month basis to pursue a very well defined roadmap, and have a bidirectional communication with the core committee to develop public health interventions as I mentioned before, and report back to the core committee the progress that they make. The core committee on the other hand sets the broad agenda on an annual basis that guides the roadmap that's also annual. To guide this workflow, let's use another stroke term, we have a global co-chairs committee that is composed of very highly recognized individuals around the continents. And these are 8 members right now who are well recognized stroke leaders like Andrew Demchuck, Sheila Martins, and just in the interest of time, I'm not going to name all the names, but they meet with us once in 2 to 3 months to review the progress globally, and also act as mentors for these regional committee.
The core committee itself is now expanded to 16 members, and the majority of us are intervention neurologists and stroke neurologists, and we have 2 stroke neurologists who are not interventionalists and 1 interventional neurologist. And these core committee members also have the regional committees divided among them to oversee. We have an advisory committee from liaisons from different societies. And we also use what are call country liaisons, who are stroke and interventional practitioners in the US who have a connection from their earlier life with different countries where they came from to the US, and they help us as a liaison between the core executive committee and the regional committee. So that's the basic structure. It's all ultimately governed by the SVIN board, but the structure seems to be working extremely well.
Dr Sarraj: That's a lot of good effort. And of course, a lot of people contributing to this, really very good to hear. And this movement started in the US, then disseminated into multiple continents. It seems that the implementation, what was done through the structure that you mentioned, correct?
Dr Yavagal: That's exactly right.
Dr Sarraj: Very, very, very good. Now you have been on for almost 6 years and many achievements have been reached, and it would be really good for the stroke community and interventional community worldwide to hear of those. You mentioned increasing the number of thrombectomies, but I'm sure there is awareness and dissemination and all of that happened that would be very good for us to hear.
Dr Yavagal: Absolutely. Absolutely, Amrou. So the progress that has been made can be categorized along 2 lines. One is the number of regional committees that have grown since the launch of the committee, since the launch of the campaign. And we are proud to say that now we are 90 regional committees in 6 continents. And that's not just thanks our efforts, but the technological revolution that occurred with the pandemic allowed us to have video meetings very easily. And tools, such as WhatsApp, allow us for real-time communication with these regional committees very easily. Which was not there even actually at the launch of the campaign, so that helped us to grow and be truly in touch with these 90 regional committees. I failed to mention in my earlier answer that we have a chief executive full-time administrator who helps us run the campaign and has her hands full, as you can imagine. And we have a project management company, Orbee's, that communicates with the regional committees on a very regular basis, and facilitates the connections between the core executive committee and the regional committee.
Having said that, the second line of progress is the different categories of activities that MT 2020+ has pursued and achieved. And those are really, the first one is education and training. We published a white paper in 2020 on world stroke day that is titled “Building Thrombectomy Systems of Care, Why and How.” Actually, “Building Thrombectomy Systems of Care in Your Region, Why and How.” And this was a multiauthor contribution from all around the globe that laid out in layman language, so nonmedical language for policymakers, why they should think of about thrombectomy and thrombectomy systems and how they could build them. This is an 86-page document that has a summary in 3 pages, but it really presents the revolution in stroke care that thrombectomy has brought to nonmedical personnel and policy makers. And that was our first big achievement. And all along the way, we've conducted meetings with regional committees attending and their personnel from the regions attending the webinars that educate thrombectomy system building and training.
And most recently, we have conducted 2 regional workshops for thrombectomy in Jamaica and in Uruguay that really were highly successful with bench top models, because for a lot of low- and middle-income countries, the experience with thrombectomy is just starting. And these workshops actually in include the technicians and nurses and the stroke team, so that it's not just a neurointerventionalist who could travel to meetings outside of their country. But when you go to that country and conduct a workshop, the entire team gets to see how to work together. And so those thrombectomy workshops. And then our big ambition is to do what is called remote observership, because again, the technological revolution that has occurred where you can with a low cost be in the angio suite in the US and be connected with a physician outside the US in real time, and they can observe you without actually having to come to the US and be in your angio suite, and you can advise them on their cases.
So remote observership program is about to be launched later this year by MT 2020. We also have connected with the [World Health Organization] and the [United Nations (UN)] to pursue our goal of making thrombectomy and essential surgery. And this day carries a lot of power where governments are then directed to pay attention to thrombectomy as a very important procedure that needs to be part of the health care policy nationally. And so we have just been accepted as part of the G4 Alliance by the UN, and this is an alliance of different surgical specialties that pursues similar goals in global health and essential surgeries. We also have pursued collaborations with multiple societies, including AHA, American Heart and American Stroke Association, the World Stroke Association, and angels, which is a similar campaign that focuses on stroke center building and thrombolysis. And we continue to grow our collaborations with different societies around the world.
And the last major achievement is really in research and registry building, which as you can imagine is critical to advancing our mission. We've published a major paper on the impact of COVID-19 on thrombectomy and stroke systems around the world. And we found that COVID, at least in the first year, that's when the paper was written, decreased the number of stroke admissions and decreased the number of thrombectomies. And we also actually studied intubation and anesthesia because there was this interaction of COVID-19 and intubation. And we found that there was actually no preponderance of no intubation or all intubation. But that sort of global research is possible now with our campaign. And we also just finished writing the manuscript for an extremely novel and important project, where we looked at the global disparity between thrombectomy access throughout the world. We sent out an over 800-person survey through the regional committees all around the world. And we got 600 complete responses, around 600. And we now have data on thrombectomy access and the number of operators per LVO, number of centers per LVO in 56 countries.
And we found a 454 disparity in thrombectomy access between the highest access country, which is Australia, and Bangladesh, which is the lowest access country. And this is after excluding countries that don't have thrombectomy at all. And so a brain saving therapy that truly reduces disability and saves lives has this severe disparity 6 years after it's becoming standard of care. And so this is the sort of research that is now possible. I failed to mention earlier, just very quickly, we have a global thrombectomy tracking app that's a smartphone app where operators or their proxies can enter de-identified cases. And these cases are geo tagged, so as long as the cases are entered, we can in real time track the number of thrombectomies throughout the world from a city and institution level to a state to country to a global level. And measure how many thrombectomies were done today, how many thrombectomies were done this month. And it depends of course on the people entering the cases, but this is a very novel achievement that MT 2020 has had with the smartphone app.
Dr Sarraj: The reality is that you have done a lot along with your colleagues moving the thrombectomy mission in many countries. And really, my personal opinion is that disseminating it in countries where this wasn't being done, those courses and pushing the envelope and involving leaders, is landmarks that your movement has done. And congratulations to you and your colleagues on all of that. That has been in the last few years, so what is the future looking like? What are the future directions and milestones that you're all set for the movement in the next few years?
Dr Yavagal: Great question. So we are, again, trying to be evidence based as we do in our clinical practice. And we found in our global survey that the determinants of access globally, the ones that stood out from multivariate regression analysis, and a couple of them were surprising for their exclusion, were actually the country's income, which is kind of obvious and we can't directly make a difference in the country's income, higher income countries have higher access. But the other determinants were really the existence of a policy of LVO triage directly with thrombectomy centers. Which we've seen in papers from the US and some of the other high-income countries, but to find this globally was eye opening. And so even in a low income country, establishing a policy of clear LVO triage determines how good your access is.
And the other one is how good your prehospital [emergency medical service] workers are educated on recognizing LVO in the field. And certainly the number of operators and the number of centers were the other indicators of access. So based on these findings, our top priorities going forward are to work with the regional committees to train more experts in every region. And the gap is actually massive, and it appears that it's going to take, with the current pace, it could take 3 decades to close the gap of the number of required operators. So, we are looking at innovative pathways of getting more thrombectomy operators trained. Establishing more centers, especially with governmental health, is another big priority. So advocating with government, which I didn't get a chance to talk about, has been another major achievement for thrombectomy. And we have managed to meet with health ministry and the health policy makers in 30 countries with the white paper and informing them about the need for their support. So with that same support, we are looking to increase the number of thrombectomy centers everywhere.
And then prehospital education and prehospital triage policy, advocating for them is going to be our top priority going forward. As I mentioned earlier, remote partnership contributes to better trained neurointerventionalists. And so while for decades observers have come physically to high-income countries, remote proctorship allows us to have more physicians getting trained in thrombectomy with remote technology, so that they don't have to spend the money and go through all the bureaucracy and have more people really get experience with thrombectomy. So those are our big goals. And the last one, again, it comes back to the real-time tracking of thrombectomy, which as you would know, is critical to establishing solutions by tracking data. Where are thrombectomies lagging behind, where are thrombectomies increasing, who's doing what right, who is not doing something and they're lagging behind, would be based on such real time tracking. So the smartphone app is being disseminated and made even more user friendly so that thrombectomies around the world can be tracked in a de-identified manner in real time.
Dr Sarraj: That's great. And I have full confidence with all of what have been done thus far, that we will see those goals and probably beyond achieved. And this great effort with you and many good people standing behind and supporting without a doubt have been achieved without funding and support from different organizations. And I want to give you the opportunity to acknowledge and thank those as you requested.
Dr Yavagal: Thank you so much, yes. There's no way to run this campaign without unrestricted grant support. And we started small as you would expect with just around $10,000, but this has really grown over the years, and we have support from companies, such as Medtronic, Microvention, and Stryker at a very high level followed by Balt, Cerenovus, and Penumbra. And these companies really are to be thanked for their unrestricted grants to us. The SVIN society underwrote the campaign for 4 to 5 years until we managed funding.
And I'd like to end by something that is very exciting. We declared May 15, 2021, as the first world thrombectomy day. And we are coming up in the next few days to celebrate and mark the world thrombectomy day number 2 on May 15th, 2022. And we are launching a year-long campaign that we want to model along the lines of the ice bucket challenge that was done for [amyotrophic lateral sclerosis] called salsa against stroke. Where the theme is that with a fast dance, we would raise public awareness about the fast signs and symptoms of stroke. And so this is going to be open to the public and details are to follow, but the tagline is, "Be fast if you can't, speak, smile, walk, talk." And so this public awareness effort is going to be worldwide through the MT 2020 campaign.
Dr Sarraj: Great. And on your behalf and your colleagues' behalf, I want to acknowledge and thank those. This is an important initiative and the support here is really very valuable, and everybody's grateful for any effort that would disseminate such a powerful treatment across the globe. That was a great summary and information about how this all started, how it grew, how it was implemented and structured, to achieve a lot of ambitious goals and go beyond that. And I really look forward to everything that you all will do in the future.
Dr Yavagal: Amrou, thank you so much, I really appreciate the opportunity. And yeah, look forward to talking to you again sometime in the future.
Dr Sarraj: Absolutely. Thank you for being with us. And our goal is to let our audience know that and inspire maybe other people to do similar movements in the future. This was again, Dr. Dileep Yavagal, the global chair of Mission Thrombectomy 2020+ with us on Neurology Learning Network. Thank you.
Amrou Sarraj, MD, is the Director of the Cerebrovascular Center and Comprehensive Stroke Center at University Hospitals Cleveland Medical Center, Director of Stroke Systems at University Hospitals Neurological Institute, Professor of Neurology at Case Western Reserve University, and George M Humphrey II endowed chair. Dr. Sarraj is an internationally recognized vascular neurologist and researcher with primary interests in endovascular thrombectomy and optimal patient selection. He graduated from Damascus School of Medicine in 2005. After finishing his internship at the University of Illinois Chicago, he completed his residency and fellowship in Vascular Neurology at the University of Texas Health Science Center at Houston in 2012. He held the positions of tenured associate professor of Neurology, director for the Vascular Neurology Fellowship program, the Chief of General Neurology service, and the Vice-chair, Clinical Quality at UTHealth Houston prior to his move to Cleveland.
Dr. Sarraj is the Global Principal Investigator of SELECT 2, which is an international randomized controlled trial assessing the efficacy and safety of endovascular thrombectomy in patients with large core strokes. He is the Principal Investigator of the SELECT trial, recently completed a multicenter United States study for imaging selection prior to endovascular thrombectomy. He has also served as the site PI for multiple other clinical trials.
Dr. Sarraj has numerous first and last-author publications in JAMA Neurology, Lancet Neurology, Annals of Neurology, Stroke and several other high-impact journals. He presented his research at multiple plenary sessions nationally and internationally and has been awarded the “Mordecai Y. T. Globus New Investigator Award in Stroke” in 2013 and the “Stroke Care in Emergency Medicine Award” in 2020 from American Heart Association/American Stroke Association.
Dileep R. Yavagal, MD, FAHA, FAAN, FSVIN, is the Director of Interventional Neurology and Co-Director of Neuroendovascular Surgery at the University of Miami & Jackson Memorial Hospitals and Clinical Professor of Neurology and Neurosurgery at the University of Miami Miller School of Medicine. He completed his MBBS and MD in Internal Medicine at Seth G. S. Medical & King Edward Memorial Hospitals in Mumbai. He did his Neurology training at Harvard followed by Neurocritical Care and Interventional Neuroradiology Fellowships at Columbia Presbyterian in NYC and UCLA respectively. He has been at the University of Miami Miller School of Medicine since 2008.
Dr Yavagal is an international thought leader in endovascular therapy for ischemic and hemorrhagic stroke as well as a pioneer in the translation of intra-arterial delivery of cell therapy for stroke. He co-led the first randomized controlled trial of Intra-arterial delivery of stem cells in ischemic stroke: RECOVER-Stroke. In 2018, he was appointed to lead the Neurological Cell Therapy Platform at the Interdisciplinary Stem Cell Institute at the University of Miami.
He has been on the steering committees of several landmark RCTs of mechanical thrombectomies including SWIFT-Prime and MR-RESCUE and current steering committee member of ongoing trials: TIGER, TESLA & CALM-2. Dr. Yavagal is the founder and Global Chair of the global Mission Thrombectomy 2020+ campaign to accelerate access to stroke thrombectomy globally and reduce regional disparities in thrombectomy access. He is the co-founder and Past-President of the Society for Vascular and Interventional Neurology (SVIN).
