ABSTRACT
Objectives: The COVID-19 pandemic has drastically altered the medical landscape. Not in our lifetime have we seen such a rapid and widespread cancellation of scheduled vascular surgical operations. The objective of this study was to evaluate the impact of COVID-19 on the care of patients with carotid disease. Methods: An interim data analysis of the Carotid module of VASCC Project 1: Impact of COVID-19 on Scheduled Vascular Operations was performed. The Vascular Surgery COVID-19 Collaborative (VASCC) was founded in March of 2020. Modules were developed by international vascular surgeon working groups and extensively beta tested before implementation. Each participating site agreed to share a collection of patient data whose vascular surgeries were postponed due to the COVID-19 pandemic. The REDCap database, housed at the University of Colorado, was determined to be exempt from Institutional Review Board review. A total of 57 patients with carotid stenosis whose surgeries were postponed during the COVID-19 pandemic surge in the USA were included in the interim data analysis. Patients whose surgeries were scheduled but not postponed were not included. Results: The mean ± SD age of the 57 patients was 70.5 ± 10.8 years. Seventy per cent were male and 28.1% were female. Seventy-two per cent of patients were white, 17.5% were Hispanic, 1.8% were Asian or Pacific Islander, and 1.8% were black. Seventy-five per cent of patients were asymptomatic, 8.8% had a cerebrovascular accident (CVA), 8.8% had a transient ischaemic attack (TIA), 3.5% had amaurosis fugax, and no patients presented with crescendo TIA (Table 1). The average length of surgical delay was 78.3 ± 36.1 days, with a median of 73 days (interquartile range 45.75 days) (Table 2). Of the 57 patients, 33 (57.9%) had surgeries postponed and successfully completed surgery at time of data entry. Seventy-two per cent of the postponement were due to intuitional policy (Table 3). No patients (0%) decompensated or required an emergency surgery during the delay. Two patients (4.0%) with carotid disease died while waiting for surgery. The cause of death of both patients was unrelated to cerebrovascular disease. Conclusions: None of the asymptomatic patients became symptomatic during the surgery delay. Two patients with carotid disease died while waiting for surgery due to causes not related to cerebrovascular disease. Our interim analysis supports institutional and national guidelines in the USA that patients with asymptomatic carotid stenosis may be safely postponed during a COVID-19 pandemic surge. Further data are needed to evaluate the impact of patients with symptomatic carotid stenosis. [Formula presented] [Formula presented] [Formula presented] [Formula presented] [Formula presented] [Formula presented]
ABSTRACT
Introduction: The evaluation and risk stratification of patients with TIA/non-disabling ischemic stroke (TIA/NDS) arriving to the Emergency Department (ED) incurs high-cost imaging and increases ED length of stay (EDLOS). We evaluated the safety and feasibility of an ED-toOutpatient Pathway for TIA/NDS. Methods: In April 2020, we developed a risk stratification algorithm for TIA/NDS in the ED using features of the clincal presentation, limited blood tests, telemetry, and head-neck CT/CTA. Patients deemed low risk based on a 'safety checklist' were discharged with plans for expedited outpatient testing as warranted (e.g., brain MRI, echocardiogram) followed by rapid outpatient follow-up. To assess safety/feasibility of this pathway, we analyzed data of the first 101 patients prospectively enrolled through October 2020. Results: Mean age 68 years (range, 33-99);53% men;median NIHSS score 0 (range 0-3). Symptom duration was classified as <10 min (24%), 10-59 min (23%), >60 min (49%), unclear (4%). Deficits included isolated weakness (16%), isolated aphasia (15%), amaurosis fugax (6%), numbness/combined deficits/other (63%). Median ABCD2 score 3 (range 1-7). Outpatient follow-up included stroke clinic (82%), primary care (4%), not required or patient declined (6%), other hospital (1%);7% were lost to follow-up;43% had follow-up within 7 days. Imaging performed in the ED included CT/CTA only (39%), MRI/MRA only (27%), both (33%), or no imaging (1%). EDLOS was significantly less for patients when CT/CTA only was performed, as per pathway (12.8 versus 16.8 hours, p<0.05). The safety checklist was followed in 69% of patients. When the checklist was used properly, there were 0 recurrent strokes or TIAs within 90-days (versus 2 when not used correctly, p<0.05). Return rates to the ED were 8% with use of checklist and 6% without use (p=0.76). Conclusion: Our TIA/NDS pathway, implemented shortly after the outbreak of Covid-19 in the USA, significantly decreased EDLOS, and still allowed for TIA/NDS patients to be safely discharged from the ED. Acceptable risk stratification and safety is suggested by the low rates of recurrent events when the pathway was followed properly. More education is needed to ensure consistent and proper use of the pathway.