Changing Venous Practice in the COVID-19 Era: “Never Let a Good Crisis Go to Waste”

Dear Editor,

The COVID-19 pandemic is having an unprecedented impact on vascular surgery practice, services, and resources worldwide. Although there are several negative consequences, we would like to share with you one positive experience of our own. The first wave of the pandemic in March 2020 found us in the midst of trying to transform our varicose vein practice from open surgery to an endovenous approach. Traditionally, this unit, based at a large inner city University Hospital, embraced modern endovascular therapies in the field of aortic aneurysm, carotid, and peripheral arterial disease. However, we failed to move with modern technology in the venous field and the management of varicose veins remained at large open surgical. Because of reduced convalescence and less pain and morbidity, current American and European professional societies’ guidelines recommend endovenous thermal ablation of the incompetent saphenous vein over open surgery.^{1 , 2} Our intention was to conform with the international guidelines and adapt varicose vein practice accordingly. Given that our unit belongs to the public sector and treats National Health Service patients, this transition from open to endovenous surgery faced several delays. These were due to the prolonged economic crisis in Greece, a tight hospital budget, bureaucracy, and the fact that hospital managers considered varicose veins as a low-priority health issue compared to other diseases, such as cancer or cardiovascular disorders. After several attempts, we were eventually fortunate to be allowed to have access to radiofrequency (RF) ablation catheters and the company who provided these agreed to loan to the hospital one RF generator (RF Medical, Seoul, South Korea) for endovenous procedures. Through a charity donation, we were able to get hold of a vascular ultrasound machine for the exclusive use by the vascular surgery team in the operating room. Up to that point, the standard procedure for a varicose vein patient with saphenofemoral junction and great saphenous vein (GSV) incompetence would have been saphenofemoral junction ligation, GSV stripping, and local stab phlebectomies. These procedures were performed under general or regional anesthesia. The unit surgeons received training on endovenous ablation procedures by attending relevant workshops in Greece and abroad.

The build up toward an endovenous service started with the vascular surgeons, themselves, getting familiar with scanning the lower limb veins prior to the procedure when marking the varicose veins. We specifically focused on saphenous vein mapping and considered whether, or not, this vein could be treated by an endovenous technique, and, if yes, which would be the ideal access point. The next step was to perform RF ablation and stab avulsions under general or regional anesthesia in a number of suitable cases with saphenous incompetence who had been admitted via the varicose vein waiting list for high ligation, GSV stripping, and phlebectomies. This helped us to standardize our endovenous technique in the operating room, particularly, in terms of obtaining access, delivering the tumescent anesthesia using an infusion pump, and thermally ablating the incompetent saphenous trunk. The procedures were completed by stab phlebectomies in the usual manner as per open surgery. The feedback from this initial experience was positive and encouraging. It was then when the first wave of the COVID-19 pandemic occurred in Greece resulting in a lockdown for several weeks and suspension of all nonurgent surgical workload.³

The gradual resumption of surgical services after the end of the lockdown in May 2020 was not easy. There was a significant decrease in the number of available anesthetic sessions, the anesthetists being busy primarily with emergency cases, both COVID and non-COVID. That left us with plenty of operating room space but no anesthetic cover. As a consequence, we were faced with the choice of either not doing any varicose vein surgery at all, or switching to a local anesthetic approach without the presence of an anesthetist. We decided that the timing was ideal to opt for the latter, i.e., an endovenous approach entirely under tumescent anesthesia. Of course, that was our plan all along, but the COVID-19 crisis accelerated this transition process. A total of 36 endovenous RF ablation cases had been performed. All operations were uneventful and both patients and surgeons were satisfied with the overall experience. To minimize the risk of patient and staff infection with COVID-19, all patients were required to provide on admission a negative COVID-19 PCR test (taken within the preceding 24–48 hr). This is, currently, a universal policy for all hospital admissions in Greece. None was found to be positive and had to be postponed, and none was found positive within a month of the procedure.

In brief, we were pleasantly surprised by the ease this service change had occurred. Similar positive experiences have been reported by others who managed to revive or reinvent their veins service as a result of the difficulties encountered during the COVID-19 crisis.⁴ Nowadays, we are in the middle of the second wave of the pandemic. Greece, and particularly our region in Northern Greece, has been hit much harder than the first wave. Again, we have a lockdown, all elective workload has been suspended, and we only treat vascular emergencies, chronic venous insufficiency not being one of these.⁵ However, the progress has been made and Winston Churchill's quote “never let a good crisis go to waste” could not fit any better.⁴ Backed by this positive experience, we are enthusiastic about being able to transform our vein practice to a modern endovenous service. Despite the detrimental effects on health care resources, the COVID-19 crisis speeded up this transformation process and we hope that something good will come of something so bad.