Vascular surgery in the COVID-19 pandemic

A novel outbreak termed coronavirus disease 2019 (COVID-19) has continued to challenge the healthcare system globally. By the beginning of April, more than 1,000,000 positive cases, with 51,737 deaths, had been reported.¹ A worldwide response to maintain the healthcare system is essential during the pandemic. The main reason for delaying the performance of elective procedures has been to ensure that the healthcare system keeps up with the pandemic. Numerous concerns have emerged regarding whether to defer vascular procedures and the protection measures necessary during the treatment of a patient with COVID-19.

In Turkey, the Ministry of Health and hospital administrators instituted certain precautions to manage this situation at the outbreak of the pandemic. Deferring elective operations and redefining major hospitals as “pandemic hospitals” were the main measures taken by authorities. Most of the larger volume cardiovascular centers have become pandemic hospitals and have mainly been treating patients with COVID-19. Although it had seemed that some hospitals at first would remain free of patients with COVID-19, the impossibility of having any COVID-free center during this rapidly increasing pandemic was realized. In this context, our center, which is also a designated pandemic hospital, has deferred all elective operations to the greatest extent possible. Also, the arrangements of the work shifts have been organized to have a vascular surgeon on duty at all times (1 day on and 4 days off for each surgeon), especially for all types of open vascular surgeries. Moreover, our endovascular surgical team, consisting of two senior and four junior surgeons, is on call for endovascular procedures at all times.

The availability of the surgical and anesthesia staff, accessibility to the operating room (OR) and angiographically suite, and readiness of surgical equipment and supplies (eg, grafts, sutures, blood products) are considered of top priority when deciding whether a patient should undergo surgery. In addition to the capacity of the healthcare center, what constitutes an emergency situation should be determined specifically for each surgical specialty. Therefore, we have used a concept of “level of priority” (LoP) for cardiovascular procedures.² The modified version of this concept for vascular surgery is summarized in Table . The classification of cases under the major headings could be relevant in terms of making decisions for patients during the pandemic. This is also essential for protecting the healthcare staff from possible and/or asymptomatic patients with COVID. Patients whose COVID status is unknown can be better identified using this classification. LoP I conditions can be delayed to the greatest extent possible. LoP II to IV conditions should be considered on an individual patient basis and the availability of the healthcare system. In our center, all patients with LoP I conditions are subjected to deferral, and our team is diligently treating all urgent and emergency cases. In the past decade, the tendency to implement endovascular procedures for many patients has prevailed in vascular surgery. The current situation might provide us with a chance to treat patients owing to the decline in the operative time for open surgery and for those using local or regional anesthesia. The latter is preferred because intubation and the use of ventilators to minimize the potential for exposure to aerosol-generating procedures are not required.³ Endovascular procedures could also be beneficial for blood conservation.

Table.

Definition of level of priority for vascular surgery

LoP I: elective surgery (routine admission for operation)

AVD

Unruptured and hemodynamically stable patients

PAD

Patients with intermittent claudication

Chronic limb ischemia with rest pain or tissue loss

Asymptomatic bypass graft or stent restenosis

AV access for hemodialysis

Fistula revision for malfunction/steal

AV fistula and graft placement for dialysis

VD

Varicose veins, ablations

Inferior vena cava filter removal

Venous stenting for asymptomatic patients

LoP II: urgent surgery (patients not electively admitted for surgery but who require intervention or surgery during the current admission for medical reasons; these patients cannot be discharged without a definitive procedure)

AVD

TAAA/AAA with acute contained rupture in hemodynamically stable patients

Rapid progression of aneurysmal diameter and large diameter TAAA/AAA (>6-6.5 cm)

Symptomatic peripheral artery aneurysm

Pseudoaneurysm (not suitable for thrombin injection and US-guided compression)

PAD

In the absence of neurologic deficit, revascularization is indicated within hours after initial imaging on a case-by-case basis

Infected arterial prosthesis without overt sepsis hemorrhagic shock or impending rupture

Surgical drainage and debridement (including minor amputation, if required) and begin antibiotic treatment for all patients with suspected chronic limb-threatening ischemia presenting with deep space foot infection or wet gangrene

Amputation for infection or necrosis and nonsalvageable limb

Symptomatic acute mesenteric ischemia

AV access for hemodialysis

Thrombosed or nonfunctional dialysis access

Infected access

AV fistula revision for ulceration

Tunneled catheter

LoP III: emergency (operation necessary before beginning of next working day after decision to operate)

AVD

TAAA/AAA and peripheral aneurysm with rupture in hemodynamically unstable patients

PAD

Acute limb ischemia (neurologic deficit in the limb, especially involving motor loss [Rutherford IIb])

Patients with acute limb ischemia secondary to acute aortic occlusion

Fasciotomy (to treat postischemic compartment syndrome)

Dissection of aorta

Type A aortic dissection

Complicated type B aortic dissection

Traumatic injury with hemorrhage

VD

Acute iliofemoral deep venous thrombosis with extensive involvement and high risk of pulmonary embolism

LoP IV: salvage (patients requiring cardiopulmonary resuscitation en route to operating room or before induction of anesthesia)

AV, Arteriovenous; AVD, Aneurysmal vascular disease; LoP, level of priority; PAD, peripheral arterial disease; TAAA/AAA, thoracoabdominal aortic aneurysm/abdominal aortic aneurysm; US, ultrasound; VD, venous disease.

Data modified from Mavioğlu Levent et al.²

Healthcare providers must provide care to their patients, which places them at a high risk of infection with COVID-19. Personal protective equipment (PPE) is a key issue for healthcare workers. A shortage of PPE has been reported by many centers. PPE for the surgical team should include certain extra equipment compared with the standardized PPE. A face shield over goggles and mask, a surgical coat, and, preferably, double gloves fixed with adhesive drapes to the surgical coat are recommended for additional protection during surgery.² In addition to the PPE, the preparation of the OR, transportation of the patient, and disinfection measures for the OR are other important concerns.²

In conclusion, the LoP concept could be of value in deciding whether to defer a vascular surgical procedure. In addition, expert opinion and correspondence could offer great value in addressing the issue of the longer term deferral of certain cases. When performing a vascular surgery (whether endovascular or open) for a patient with suspected or confirmed COVID-19, full protection should be supplied to the healthcare workers in the OR and angiographic suite.