The question of the COVID-19 pandemic’s effect on vascular practice continues to occupy members of the specialty. Contributors to a global vascular surgery registry collecting data on its impact on scheduled operations and virus-related thrombotic complications detailed a series of practice experiences as the pandemic entered the winter surge.
The Vascular Surgery COVID-19 Collaborative (VASCC) aims to catalogue how the coronavirus has affected procedures across the five major areas of vascular practice and conditions to include carotid, aortic, peripheral, venous and hemodialysis modules (project one). VASCC’s second focus on thrombotic complications is investigating the virus’ connections to acute limb ischemia, acute mesenteric ischemia, stroke and symptomatic venous thromboembolism (project two).
“The winter surge is hitting the U.S. and Europe hard,” notes registry co-founder Max Wohlauer, MD, assistant professor of surgery in the division of vascular surgery at the University of Colorado School of Medicine in Aurora. “Hospitals are placing severe limitations on scheduled surgeries and vascular surgeons are seeing increases in thrombotic complications of COVID.”
As VASCC continues to collect data and enroll new sites both inside the U.S. and internationally, fellow co-founder Robert F. Cuff, MD, program director for integrated vascular surgery residency at Spectrum Health-Michigan State University in Grand Rapids, emphasizes how far-reaching the registry has been. “VASCC is truly a worldwide international effort with sites in Europe, Australia, Asia, the Middle East and the U.S. It truly has been as wide an effort as the Pandemic itself.”
At the beginning of December, Vascular Specialist spoke with some of the VASCC contributors at a number of sites and heard about how the winter surge was impacting on practice and thrombotic complications.
Probing questions
Jens Eldrup-Jorgensen, MD, of the division of vascular and endovascular surgery, at Maine Medical Center in Portland, Maine, pointed to the kind of questions he’s asking in light of COVID-19’s association with arterial and venous thrombotic events. “What extent will this virus impact vascular patients who are predisposed to thrombotic events, i.e., pre-existing arterial occlusive disease or thrombogenic surfaces, e.g., stents or grafts?” he pondered. “How will the COVID-19 virus impact treatment of arterial disease, for example increased postoperative thrombotic events affecting stent or graft patency, coronary artery thrombosis, cerebrovascular thrombosis, or venous thromboembolic events and other postoperative complications—such as pulmonary complications—all of which could occur early or late.”
Eldrup-Jorgensen added: “Patients are reluctant to come to the [emergency room] or hospital. How will this delay impact pre-existing arterial disease? For example, will untreated carotid stenosis progress to [a cerebrovascular accident], will untreated AAA [abdominal aortic aneurysm] rupture—and will untreated lower-extremity occlusive disease—progress to gangrene, sepsis and
limb loss?”
In Dallas, Fatemeh Malekpour, MD, an assistant professor of vascular and endovascular surgery at the University of Texas (UT) Southwestern, Dallas, contrasted the initial March–May 2020 period with June–August, and the months up to the beginning of December.
As the initial period unfolded, she said, “we started to make a list of patients who were affected by the pandemic: an elective AAA that ruptured and [the patient] died at home, an SMA [superior mesenteric artery] open thrombectomy patient who was eventually discharged, COVID toes, deep vein thromboses. VASCC was solidifying and UT Southwestern joined the collaborative.”
Then, from June to August, new cases were slowing down, Malekpour stated, and operating rooms started to re-open. “Summer and fall revealed that Texas is having more cases every day, and soon it took over New York, Florida and California,” she continued. “Even though the death rate was not as high, we still had ongoing high daily new cases and deaths.
“In the couple of months till now, which is December, Texas remained number one at total case number, and most of the times daily new deaths. We are still doing scheduled elective procedures at Parkland Memorial Hospital and the university hospital. All patients should have a COVID test to come to pre-op, and this has been the rule for more than four months. After both hospitals agreed to participate in VASCC, and we obtained access to the UT Southwestern COVID registry, our team completed project one of VASCC. We are about to start project two using the institution registry,” Malekpour added.
Learning curve
Brigitte K. Smith, MD, program director of the vascular surgery fellowship at the University of Utah School of Medicine in Salt Lake City, speaks of how, during the second wave, she and colleagues have been able to “fine-tune” what is canceled or rescheduled.
“For example, a patient presenting with limb ischemia that we might previously have approached with lysis, we wouldn’t offer lysis because it takes multiple days, multiple trips to the operating room—lots of personal protective equipment—and an intensive care unit [ICU] bed,” she says. “The patient with critical limb ischemia that was 2a would either get thrombectomy/bypass, or be sent home with a very low ankle-brachial index [ABI], albeit not an immediately threatened limb. Now we have our supply chain for PPE [personal protective equipment] figured out so that isn’t a consideration.”
Cheong Jun Lee, MD, division chief of vascular surgery at NorthShore University Health System in the Chicago area, said VASCC project one might yield “help with coordinating a more appropriate, data-driven postponement for certain disease conditions in this second surge we are experiencing.”
Meanwhile, Lee sees timeliness with VASCC project two on thrombotic complications, which went live on Nov. 19. “As we saw in the first surge in spring, we at NorthShore are seeing another wave of serious thromboembolic issues associated with COVID-19—three serious arterial occlusion events were recently seen by our team since the beginning of this second surge, one patient with a carotid occlusion and transient ischemic attack who is doing well with anticoagulation, and two patients with acute aortic thrombosis; one who underwent thrombolysis for distal embolization of the thrombus and who responded well, except will lose a toe; and one with complete infrarenal occlusion, resulting in paralysis and lower-limb ischemia who underwent open thrombectomy and is recovering in the ICU, but has renal and hepatic dysfunction.”
Of note, Lee added, none of those patients presented with the serious respiratory issues anticipated with COVID on presentation. “Although these patients had underlying medical comorbidities, the profound hypercoagulability realized with COVID-19 certainly is a clinical driver for these events,” he said. “VASCC project two aims to capture important data from these challenging—but valuable—experiences of vascular surgeons handling serious thrombotic complications of COVID-19 patients, and it is critical we get a robust participation from our vascular surgery community.”
Italian experience
Gabriele Piffaretti, MD, associate professor of vascular surgery at University of Insubria School of Medicine in Varese, Italy, said he and colleagues had experienced two very different situations over the course of the pandemic. “During the first wave, here in Varese we saw very few vascular complications, more frequently in the form of massive pulmonary embolism that indeed jeopardized a potentially good clinical outcome after weeks of non-invasive ventilation, or ICU treatment.
“In the second phase, Varese has been and still is the area with the greatest incidence of infection and number of hospitalized COVID patients in the entire national territory. However, information gained from the first phase, as well as the ability to treat these patients at the very early onset of the respiratory insufficiency, most likely allowed us to smooth the incidence of vascular complications in our area.
“Acute limb ischemia, mesenteric ischemia, and carotid thrombosis remain the main vascular complications observed since Oct. 18, the date of the start of the second wave in our area.”
Drawing from her experience, Laura Nicolai, MD, of the vascular surgery unit at Cà Foncello Hospital in Treviso, Italy, described thrombosis of the small vessels and pedal arch as the main problem encountered.
“In two middle-aged patients with COVID-19 who presented with acute lower-limb ischemia, we performed a transpopliteal balloon embolectomy, but the acute limb ischemia recurred, despite anticoagulation,” she said. “In both of them, the problem was solved performing an arteriovenous fistula between anterior tibial vein and artery and posterior tibial vein and artery at the ankle, because there was no run off due to thrombosis of small vessels and pedal arch.”
