key: cord-347935-jfx9037u
authors: Valdivia, Andrés Reyes; Sanus, Enrique Aracil; Santos, África Duque; Olmos, Cristina Gómez; Alguacil, Sergio Gordillo; El Amrani, Mehdi; Guaita, Julia Ocaña; Zúñiga, Claudio Gandarias
title: Adapting vascular surgery practice to the current COVID-19 era at a tertiary academic center in Madrid.
date: 2020-06-04
journal: Ann Vasc Surg
DOI: 10.1016/j.avsg.2020.06.001
sha: 
doc_id: 347935
cord_uid: jfx9037u

INTRODUCTION: The epidemic potential of Coronavirus infection is now a reality. Since the first case detected in late 2019 in China a fast-world-wide expansion confirms it. The vascular patient is at a higher risk of developing a severe form of the disease due to its nature associating several comorbid states and thus, some Vascular Surgery communities from many countries have tried to stratify patients into those requiring care during these uncertain times. METHODS: Observational study describing the current daily vascular surgery practice at one tertiary academic hospital in Madrid region, Spain; one of the most affected regions worldwide due to the COVID-19 outbreak. We analyzed our surgical practice since March 14(th) when the lockdown was declared up to date, May 14(th) (2 months). Procedural surgical practice, organizational issues, early outcomes and all the troubles encountered during this new situation are described. RESULTS: Our department is composed of 10 vascular surgeons and 4 trainees. Surgical practice has been reduced to only urgent care, totaling 50 repairs on 45 patients during the time period. Five surgeries were performed on 3 COVID-19 positive patients. Sixty percent were due to CLI, 45% of them performed by complete endovascular approach; whereas less than 10% of repairs were aorta related. We were allocated to use a total of 5 surgical rooms in different locations, none our usual, as it was converted into an ICU room while performing 50% of those repairs with unusual nursery staff. CONCLUSIONS: The COVID-19 outbreak has dramatically changed our organization and practice in favor of urgent or semi-urgent surgical care alone. The lack for in-hospital/ICU beds and changing nursery staff changed the whole availability organization at our hospital and was a key factor in surgical decision making in some cases.

The epidemic potential of Coronavirus infection is now a reality. Since the first case 72 detected in late 2019 in China a fast-world-wide expansion confirms it. The vascular 73 patient is at a higher risk of developing a severe form of the disease due to its nature 74 associating several comorbid states and thus, some Vascular Surgery communities from 75 many countries have tried to stratify patients into those requiring care during these 76 uncertain times. 77 78

Observational study describing the current daily vascular surgery practice at one tertiary 80 academic hospital in Madrid region, Spain; one of the most affected regions worldwide 81 due to the COVID-19 outbreak. We analyzed our surgical practice since March 14 th 82 when the lockdown was declared up to date, May 14 th (2 months). 83

Procedural surgical practice, organizational issues, early outcomes and all the troubles 84 encountered during this new situation are described. 85 86

Our department is composed of 10 vascular surgeons and 4 trainees. Surgical practice 88 has been reduced to only urgent care, totaling 50 repairs on 45 patients during the time 89 period. Five surgeries were performed on 3 COVID-19 positive patients. Sixty percent 90 were due to CLI, 45% of them performed by complete endovascular approach; whereas 91 less than 10% of repairs were aorta related. We were allocated to use a total of 5 92 surgical rooms in different locations, none our usual, as it was converted into an ICU 93 room while performing 50% of those repairs with unusual nursery staff. 94 95

The COVID-19 outbreak has dramatically changed our organization and practice in 97 favor of urgent or semi-urgent surgical care alone. The lack for in-hospital/ICU beds 98 and changing nursery staff changed the whole availability organization at our hospital 99

and was a key factor in surgical decision making in some cases. The first reported case in Spain was in January 31 st and since then, the rapid spread of 112 the virus has been demonstrated as the numbers of confirmed diagnosis (231 000) and 113 deaths (27650) have dramatically increased daily, with the last week reaching the 114 smaller number of deaths per day (less than 100). 115

The vascular patient due to its nature associating several comorbid states should be 116 considered at higher risk when compared to other populations 3 . Some Vascular Surgery 117 communities have tried to stratify patients into those requiring urgent care during this 118 pandemic situation, i.e >70mm abdominal aortic aneurysms or ruptured AAA, critical 119 limb ischemia (CLI) and symptomatic carotid disease 4 . Hospital organization strictly 120 depends on the pandemic situation, as in-hospital and intensive care unit beds (ICU) 121 availability, surgical rooms disposal and nursery staff. Observational study describing the current daily practice at one tertiary academic 126 hospital in Madrid region, Spain; one of the most affected regions worldwide due to the 127 COVID-19 outbreak. We analyzed our surgical practice since March 14 th when the 128 lockdown was declared up to date (8 weeks). 129

Procedural surgical practice, organizational issues, early outcomes and all the troubles 130 encountered during this new situation are described. Our surgical activity has dramatically been reduced to minimums. We only provided 139 surgical care for urgent cases, and during the last two weeks, as the COVID-19 situation 140 improved and more in-hospital beds and resources are available, we started to provide 141 care to patients requiring a vascular access, limb ischemia with rest pain and one carotid 142 with severe stenosis with unstable plaque. Figure 1 shows a pie-chart with those 143 procedures performed during the study period, describing on 60 interventions performed 144 in 50 patients. 145

All surgical procedures were performed outside our usual surgical room. We have 146 changed our surgical room 5 times (like nearly all the other surgical departments) 147

whereas up to 50% of repairs have been performed without our usual nursery staff. 148

The vast majority of interventions were related to CLI revascularization (60%), where 149 nearly 40% where performed by open means, as shown in Figure. 2.

Aorta-related disease was required for 5 patients. One patient receiving an axillo-151 femoral by pass due to aortic-graft thrombosis, was tested positive for Covid-19 and 152

after two re-interventions (one explantation and contralateral axillo-femoral 153 revascularization and one other for acute axillar stump bleeding) died for ARDS (acute 154 respiratory distress syndrome). 155

Three patients received successful TEVAR treatment for acute aortic syndromes, one 156 case with symptomatic thoracic aortic ulcer, one with intramural hematoma (IMH) and 157 the other with post-dissection symptomatic aneurysm. 158 The challenge, as vascular surgeons, was the trouble in decision making on who and 192 how to operate, as we were dealing with our worst situation in terms of lack of 193 resources (limitation of ICU beds, in hospital beds, anesthesia team treating patients, nurse staff in other labors, etc.). 8 Referral was not an option as this same 195 situation was clearly evident for all private and public hospitals in the region. 196

Fortunately, in our center every patient requiring urgent care did receive it at last. With 197 lot of troubles due to a constant change in surgical rooms and nursery team. 198

At the peak of the outbreak, our department was split in two groups, where half of it 199 was in COVID-19 attention and the remaining on specific vascular surgery care. This 200 organization being dynamic depending on in-hospital COVID-19 and/or vascular care 201

At the very beginning of the outbreak, we dealt with a disturbing lack of tests for 203 patients and health care professionals. At some point, and this is already stablished, 204 every patient requiring hospitalization received a pharyngeal swab test for diagnosis. If 205

one needing surgical care was tested positive, one dedicated COVID-19 surgical room 206 was provided. 207

During these 8 weeks, we have performed 60 operations in 50 patients. As shown in 208 figure 1, those were mainly for CLI representing 60% of our practice. As described 209 previously, COVID-19 patients can associate a pro-coagulant state which can lead 210 either to deep vein thrombosis (DVT) and /or peripheral arterial thrombosis. These 211 patients with acute limb ischemia required most of the times urgent surgery, a situation 212 we dealt with in two cases. Pertaining DVT, a previous description of 23% incidence 213 for COVID-19 patients in ICU and 8% not requiring ventilator demonstrated the 214 importance of such situation in these patients. 7 A national registry (NCT04361981) is 215 currently starting to better understand this situation and provide accurate data in the near 216

Interestingly, from those treated for CLI, 40% were treated by open revascularization 218 techniques in our department. This in part due the aforementioned limitations related to 219 organization, as the recommendations standards given by other vascular communities is 220 directed towards total endovascular approach. We also treated 5 patients with aortic 221 diseases, and one of them would have received a different treatment in normal 222

conditions. The decision to perform an axillo-femoral by pass was due to the risk of 223 visceral embolization and absolute lack of ICU bed. Three other patients received 224 TEVAR for IMH, thoracic PAU and enlarging symptomatic TAA respectively; despite 225 the limitations, as the open options were extremely risky. The benefits of 226 EVAR/TEVAR during the COVID-19 outbreak have been described. 9 10 227 Two patients were treated for carotid disease, with conventional patch endarterectomy 228 and 7 patients for hemodialysis access (fistula creation) by open means as well. 229

Although endovascular procedures are highly recommended during these times being 230 less invasive and needing less in-hospital resources; we needed to adapt our decisions 231 and surgical actions to the changing reality in our hospital, where lack of ICU beds and 232 changes in surgical rooms and nursery staffs had a clear incidence in our decisions. 233

Finally, from those with positive test for COVID-19; 2 were CLI with successful repair 234 and the remaining, the abovementioned case of aortic graft thrombosis who 235 unfortunately died for acute respiratory distress syndrome. The increased risk of fatality 236 for a surgical repair in COVID-19 patients is previously described. 11 237

We are now into the "going back to the normal" process; however, a considerable grade 239 of uncertainty comes for the future where our weakened health system will need to deal 240 with an unprecedent scenario that might surpass again our available resources. 241 242

The COVID-19 outbreak has dramatically changed our organization and practice in 244 favor of urgent or semi-urgent surgical care alone. The lack for in-hospital/ICU beds 245 and changing nursery staff changed the whole availability organization at our hospital 246

and was a key factor in surgical decision making in some cases. 

Cardiovascular examination should 251 also include peripheral arterial evaluation for COVID-19 patients

Acute limb ischemia in patients with 254

COVID-19 pneumonia

Characteristics and outcomes of patients 256 hospitalized for COVID-19 and cardiac disease in Northern Italy

VASCULAR SURGERY ACTIVITY CONDITION IS A 259 COMMON LANGUAGE FOR UNCOMMON TIMES

Hypogastric Chimney Patency in 262

Aortic Monoiliacal Endograft Thrombosis: A Life Saved by Collateral Pelvic 263

Impact of the Covid-19 Pandemic on Vascular Surgery

Lombardia (Italy) during the first month of the COVID-19 outbreak

Vascular Life During 271 the COVID-19 Pandemic Reminds Us to Prepare for the Unexpected

Endovasc Surg 2020 2020/05/25

Endovascular treatment of a ruptured 274 pararenal abdominal aortic aneurysm in a COVID-19 patient: suggestions and case 275 report

Aortic Disease in the Time of COVID: 277 Repercussions on Patient Care at an Academic Aortic Center

Surgical Practice: Unexpected Fatality in Perioperative Period