Editor's Choice - Update of the European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia in Light of the COVID-19 Pandemic, Based on a Scoping Review of the Literature.

OBJECTIVE: To perform a scoping review of how patients with COVID-19 are affected by acute limb ischaemia (ALI) and evaluate the recommendations of the 2020 ESVS ALI Guidelines for these patients. METHODS: Research questions were defined, and a systematic literature search was performed following the PRISMA guidelines. Abstracts and unpublished literature were not included. The definition of ALI in this review is in accordance with the ESVS guidelines. RESULTS: Most identified papers were case reports or case series, although population based data and data from randomised controlled trials were also identified. In total, 114 unique and relevant papers were retrieved. Data were conflicting concerning whether the incidence of ALI increased, or remained unchanged, during the pandemic. Case reports and series reported ALI in patients who were younger and healthier than usual, with a greater proportion affecting the upper limb. Whether or not this is coincidental remains uncertain. The proportion of men/women affected seems unchanged. Most reported cases were in hospitalised patients with severe COVID-19. Patients with ALI as their first manifestation of COVID-19 were reported. Patients with ALI have a worse outcome if they have a simultaneous COVID-19 infection. High levels of D-dimer may predict the occurrence of arterial thromboembolic events in patients with COVID-19. Heparin resistance was observed. Anticoagulation should be given to hospitalised COVID-19 patients in prophylactic dosage. Most of the treatment recommendations from the ESVS Guidelines remained relevant, but the following were modified regarding patients with COVID-19 and ALI: 1) CTA imaging before revascularisation should include the entire aorta and iliac arteries; 2) there should be a high index of suspicion, early testing for COVID-19 infection and protective measures are advised; and 3) there should be preferential use of local or locoregional anaesthesia during revascularisation. CONCLUSION: Although the epidemiology of ALI has changed during the pandemic, the recommendations of the ESVS ALI Guidelines remain valid. The above mentioned minor modifications should be considered in patients with COVID-19 and ALI.

A proposed model for a comprehensive virtual subinternship in vascular surgery.

OBJECTIVE: In the present study, we sought to understand the challenges, advantages, and applications of a vascular surgery virtual subinternship (VSI) curriculum. METHODS: Our institution hosted 25 students for two 4-week VSI rotations, one in July 2020 and one in August 2020. The students participated in a curriculum centered around the use of Zoom and telephone interactions with residents and faculty. The curriculum included selected readings, surgical videos, group didactics, and one-on-one mentorship. Anonymous pre- and postrotation self-assessments were used to ascertain the students' achievement of the learning objectives and the utility of the educational tools implemented during the rotation. The faculty and resident mentors were also surveyed to assess their experience. RESULTS: With the exception of knot-tying techniques (P = .67), the students reported significant improvement in their understanding of vascular surgery concepts after the virtual elective (P < .05). The highest ranked components of the course were interpersonal, including interaction with faculty, mentorship, and learning the program culture. The lowest ranked components of the course were simulation training and research opportunities. The rating of the utility of aspects of the course were consistent with the ranking of the components, with faculty interaction receiving the highest average rating. The ideal amount of time for daily virtual interaction reported by the students ranged from 3 to 6 hours (median, 4 hours). Overall, most of the mentors were satisfied with the virtual course. However, they reported limited ability to assess the students' personality and fit for the program. The time spent per week by the mentors on the virtual vascular surgery rotation ranged from 2 to 7 hours (median, 4 hours). Of the 17 mentors completing the surveys, 14 reported that having a virtual student was a significant addition to their existing workload. CONCLUSIONS: Overall, our student and mentor feedback was positive. Several challenges inherent to the virtual environment still require refinement. However, the goals of a VSI are distinct and should be explored by training programs. With changes to healthcare in the United States on the horizon and the constraints resulting from the severe acute respiratory syndrome coronavirus 2 pandemic, implementing a virtual away rotation could be an acceptable platform in our adaptations of our recruitment strategies.

Effects of coronavirus disease 2019 on the Society for Vascular Surgery Vascular Quality Initiative arterial procedure registry.

In the present report, we have described the abrupt pivot of Vascular Quality Initiative physician members away from standard clinical practice to a restrictive phase of emergent and urgent vascular procedures in response to the coronavirus disease 2019 (COVID-19) pandemic. The Society for Vascular Surgery Patient Safety Organization queried both data managers and physicians in May 2020 to discern the effects of the COVID-19 pandemic. Approximately three fourths of physicians (74%) had adopted a restrictive operating policy for urgent and emergent cases only. However, one half had considered "time sensitive" elective cases as urgent. Data manager case entry was affected by both low case volumes and low staffing resulting from reassignment or furlough. A sevenfold reduction in arterial Vascular Quality Initiative case volume entry was noted in the first quarter of 2020 compared with the same period in 2019. The downstream consequences of delaying vascular procedures for carotid artery stenosis, aortic aneurysm repair, vascular access, and chronic limb ischemia remain undetermined. Further ramifications of the COVID-19 pandemic shutdown will likely be amplified if resumption of elective vascular care is delayed beyond a short window of time.

Vascular Surgery Practice Guidelines during COVID-19 Pandemic in a Setting of High Work Volume Against Limited Resources: Perspective of a Developing Country.

BACKGROUND: The situation of coronavirus disease 2019 (COVID-19) pandemic in the Indian subcontinent is worsening. In Bangladesh, rate of new infection has been on the rise despite limited testing facility. Constraint of resources in the health care sector makes the fight against COVID-19 more challenging for a developing country like Bangladesh. Vascular surgeons find themselves in a precarious situation while delivering professional services during this crisis. With the limited number of dedicated vascular surgeons in Bangladesh, it is important to safeguard these professionals without compromising emergency vascular care services in the long term. To this end, we at the National Institute of Cardiovascular Diseases and Hospital, Dhaka, have developed a working guideline for our vascular surgeons to follow during the COVID-19 pandemic. The guideline takes into account high vascular work volume against limited resources in the country. METHODS: A total of 307 emergency vascular patients were dealt with in the first 4 COVID-19 months (March through June 2020) according to the working guideline, and the results were compared with the 4 pre-COVID-19 months. Vascular trauma, dialysis access complications, and chronic limb-threatening ischemia formed the main bulk of the patient population. Vascular health care workers were regularly screened for COVID-19 infection. RESULTS: There was a 38% decrease in the number of patients in the COVID-19 period. Treatment outcome in COVID-19 months were comparable with that in the pre-COVID-19 months except that limb loss in the chronic limb-threatening ischemia patients was higher. COVID-19 infection among the vascular health care professionals was low. CONCLUSIONS: Vascular surgery practice guidelines customized for the high work volume and limited resources of the National Institute of Cardiovascular Diseases and Hospital, Dhaka were effective in delivering emergency care during COVID-19 pandemic, ensuring safety of the caregivers. Despite the fact that similar guidelines exist in different parts of the world, we believe that the present one is still relevant on the premises of a deepening COVID-19 crisis in a developing country like Bangladesh.

The role of Angiology and Vascular Surgery in the COVID-19 pandemic.

The New Coronavirus Epidemic (2019-nCoV), discovered in the city of Wuhan, China, in December 2019, presents mainly with pulmonary pneumonia that is preceded by fever, cough and myalgia. However, as the disease spread globally and the number of hospitalizations increased exponentially, it was noted that most serious patients hospitalized by COVID-19 have laboratory changes worthy of attention, such as lymphopenia, neutrophilia, increased time of prothrombin and increased levels of D-dimer. Due to these changes proving to be crucial for the mortality and morbidity rates in this subset of infected people, several studies focusing on the pathophysiology, mainly hematological, of the disease appear every day. Deepening these studies, several published works have shown SarsCoV-2 infection to the installation of a prothrombotic state in hospitalized patients, which leads to the potential occurrence of thrombotic or arterial events in this cohort. Thus, in order to understand how the departments of Angiology and Vascular Surgery are acting in the context of the COVID-19 pandemic, this work aims to gather studies that reveal from protocols applied in vascular services in the current situation, until to the role of vascular surgeons and angiologists in the clinical and surgical management of patients infected or not, as a way of helping and clarifying this specialty during the context of a pandemic due to the new coranavirus. For the selection of works, the following search criteria were used: "Coronavirus and venous thrombosis", "Coronavirus and thrombosis", "COVID-19 and venous thrombosis" and "COVID-19 Coronavirus and thrombosis".

Early vascular surgery response to the COVID-19 pandemic: Results of a nationwide survey.

OBJECTIVE: The COVID-19 pandemic has had major implications for the United States health care system. This survey study sought to identify practice changes, to understand current personal protective equipment (PPE) use, and to determine how caring for patients with COVID-19 differs for vascular surgeons practicing in states with high COVID-19 case numbers vs in states with low case numbers. METHODS: A 14-question online survey regarding the effect of the COVID-19 pandemic on vascular surgeons' current practice was sent to 365 vascular surgeons across the country through REDCap from April 14 to April 21, 2020, with responses closed on April 23, 2020. The survey response was analyzed with descriptive statistics. Further analyses were performed to evaluate whether responses from states with the highest number of COVID-19 cases (New York, New Jersey, Massachusetts, Pennsylvania, and California) differed from those with lower case numbers (all other states). RESULTS: A total of 121 vascular surgeons responded (30.6%) to the survey. All high-volume states were represented. The majority of vascular surgeons are reusing PPE. The majority of respondents worked in an academic setting (81.5%) and were performing only urgent and emergent cases (80.5%) during preparation for the surge. This did not differ between states with high and low COVID-19 case volumes (P = .285). States with high case volume were less likely to perform a lower extremity intervention for critical limb ischemia (60.8% vs 77.5%; P = .046), but otherwise case types did not differ. Most attending vascular surgeons worked with residents (90.8%) and limited their exposure to procedures on suspected or confirmed COVID-19 cases (56.0%). Thirty-eight percent of attending vascular surgeons have been redeployed within the hospital to a vascular access service or other service outside of vascular surgery. This was more frequent in states with high case volume compared with low case volume (P = .039). The majority of vascular surgeons are reusing PPE (71.4%) and N95 masks (86.4%), and 21% of vascular surgeons think that they do not have adequate PPE to perform their clinical duties. CONCLUSIONS: The initial response to the COVID-19 pandemic has resulted in reduced elective cases, with primarily only urgent and emergent cases being performed. A minority of vascular surgeons have been redeployed outside of their specialty; however, this is more common among states with high case numbers. Adequate PPE remains an issue for almost a quarter of vascular surgeons who responded to this survey.

Emerging practice patterns in vascular surgery during the COVID-19 pandemic.

OBJECTIVE: Ever since the first positive test was identified on January 21, 2020, Washington State has been on the frontlines of the coronavirus disease 2019 (COVID-19) pandemic. Using information obtained from Italian surgeons in Milan and given the concerns regarding the increasing case numbers in Washington State, we implemented new vascular surgery guidelines, which canceled all nonemergent surgical procedures and involved significant changes to our inpatient and outpatient workflow. The consequences of these decisions are not yet understood. METHODS: The vascular surgery division at Harborview Medical Center immediately instituted new vascular surgery COVID-19 practice guidelines on March 17, 2020. Subsequent clinic, operative, and consultation volume data were collected for the next 4 weeks and compared with the historical averages. The Washington State case and death numbers and University of Washington Medical Center (UW Medicine) hospital case volumes were collected from publicly available sources. RESULTS: Since March 10, 2020, the number of confirmed positive COVID-19 cases within the UW Medicine system has increased 1867%, with floor and intensive care unit bed usage increasing by 120% and 215%, respectively. After instituting our new COVID-19 guidelines, our average weekly clinical volume decreased by 96.5% (from 43.1 patients to 1.5 patients per week), our average weekly surgical volume decreased by 71.7% (from 15 cases to 4.25 cases per week), and our inpatient consultation volume decreased to 1.81 consultations daily; 60% of the consultations were completed as telemedicine "e-consults" in which the patient was never evaluated in-person. The trainee surgical volume has also decreased by 86.4% for the vascular surgery fellow and 84.8% for the integrated resident. CONCLUSIONS: The COVID-19 pandemic has changed every aspect of "normal" vascular surgical practice in a large academic institution. New practice guidelines effectively reduced operating room usage and decreased staff and trainee exposure to potential infection, with the changes to clinic volume not resulting in an immediate increase in emergency department or inpatient consultations or acute surgical emergencies. These changes, although preserving resources, have also reduced trainee exposure and operative volume significantly, which requires new modes of education delivery. The lessons learned during the COVID-19 pandemic, if analyzed, will help us prepare for the next crisis.