Moving forward with elective vascular work: a reflection on the impact of COVID-19 on a regional vascular hub.

INTRODUCTION: Following the initial COVID-19 surge in the UK, there was a national incentive for elective vascular surgery to be restricted to 'clean' sites to reduce perioperative cross-infection and subsequent mortality. We assessed the risk of dying from perioperatively acquired COVID-19 during the peak of the London outbreak. METHODS: Forty-three consecutive patients who had vascular (n=48) procedures in March and April 2020 at a regional hub serving five London hospitals were analysed. The patients were screened for COVID-19 in the 30-day postoperative period and the main outcome measure was mortality from COVID-19. A comparison was then made with patients who underwent minimally invasive procedures in our integrated interventional radiology department. Median follow-up was 41 days (interquartile range 8-58) overall. RESULTS: Three patients (7%) in the vascular group (median age 61 years, all diabetic, two male) died from COVID-19, all of whom tested positive postoperatively. Two others became positive but recovered. In comparison, two patients (2%) in the interventional radiology group died from COVID-19; however, one was positive prior to their procedure. CONCLUSION: Only urgent vascular cases should be performed during a COVID-19 surge. However, with growing waiting lists for elective surgery following the pandemic's second wave, further restrictions may not be a viable long-term solution. When prevalence of the disease is lower and if resources allow, resumption of care at 'hot' sites should be considered, if safety measures can be implemented. The advantages of minimally invasive surgery may also reduce risk.

Central venous access in ventilated COVID-19 patients: A vascular surgery perspective

Introduction: The number of patients on intensive care units (ICU) increased manifold during the initial COVID-19 surge and medical staff were relocated to help compensate. The need for central venous catheters (CVCs) increased accordingly and comprised a significant workload under challenging circumstances. Several models were proposed to manage the lines. We assigned a vascular team of vascular surgeons and interventional radiologists for CVCs in ICU. We report on the workload outcomes and lessons learned Method: 50 consecutive ventilated COVID-19 patients in ICU (median age 63 years, 80% male) who had a CVC inserted by the vascular team from March to May 2020 were assessed. Median follow up was 18 days (range 14- 29 days) after ICU admission Result: 166 CVCs (80 VasCaths) were inserted. Femoral access was preferred Each patient required a median of 3 lines (IQR 2-4). CVCs were exchanged after median 7 days (IQR 4-9) for thrombosis (35%), infection (24%) or prophylactically (41%). Our learning curve included the establishment of an online referral pathway, CVC teams of two operators extended disposable CVC kits and ICU based ultrasound scanners Additional staffing and retraining were avoided. There were no technical complications Conclusion: Ventilated COVID-19 patients require multiple CVCs which is a challenging workload during a pandemic. Vascular surgeons and interventional radiologists with endovascular skills are well positioned to perform central venous cannulation to alleviate the burden on critical care teams. Our lessons learned can help to provide a safe and efficient model amidst the ongoing national outbreaks Take-home Message: With the postponement of many elective vascular procedures during the pandemic crisis, the involvement of vascular surgeons in a dedicated Lines team is an important way that they can contribute given their proficiency with wires and cannulation equipment as well as familiarity in femoral triangle and jugular anatomy The retraining of staff and additional on-call rotas can then be avoided .

COVID-19 mortality after vascular procedures during the initial UK surge: Moving forward with elective vascular work

Introduction: Following the initial COVID-19 surge in the United Kingdom, there was a national incentive for elective vascular surgery to be restricted to clean sites in order to reduce perioperative cross infection and subsequent mortality. We assessed the risk of dying from perioperatively acquired COVID-19 during the peak of the London outbreak Materials and Methods: 43 consecutive patients who had vascular (n=48) procedures in March and April 2020 at a regional hub serving five London hospitals were analysed. The patients were screened for COVID-19 in the 30-day postoperative period and the main outcome measure was mortality from COVID-19. A comparison was then made with patients who underwent minimally invasive procedures from our integrated interventional radiology department. Median follow-up was 41days (IQR 8-58 days) Result: Three patients (7%) in the vascular group (median age 61 years all diabetic, two male) died from COVID-19, all of whom tested positive postoperatively. Two others became positive but recovered. In comparison two patients (2%) in the interventional radiology group died from COVID-19, however one was positive prior to their procedure Conclusion: Only urgent vascular cases should be performed during a COVID-19 surge, with elective work delayed or continued at clean sites However, with growing waiting lists for elective surgery currently, further restrictions may not be a viable long-term solution. Resumption of care at hot sites should be considered, if resources allow for it and if safety measures can be implemented. The advantages of minimally invasive surgery may inherently reduce risk as well Take-home Message: Only urgent vascular cases should be performed during a peak outbreak of COVID-19, however we cannot continue to postpone elective procedures indefinitely or restrict all cases to solely clean sites. The resumption of care at hot sites encompasses a fine balance of risks versus benefits .