Impact of COVID-19 on vascular surgery practice

       Fig. Impact of COVID -19 on Vascular Surgery

The pandemic is still growing, but our knowledge of it also continues to improve. The outlook is optimistic considering that some patients have already been cured of it and a vast amount of knowledge has been gathered so far. Also, young doctors are incorporating this priceless experience into their personal and professional growth.

Vascular surgery: Elective surgery and outpatients 

Most arterial surgery is either urgent or emergency in nature and should continue at present where possible.  

Outpatients: Where possible, only urgent outpatients should be seen, and virtual clinics should be considered.

On discharge, many vascular patients will either need no outpatient follow (but be given a telephone number to ring if in trouble) or can be reviewed in remote outpatient clinics. 

Elective surgery: Elective arterial surgery and venous surgery should be deferred. Asymptomatic carotid surgery and surgery for claudication should be deferred. The size threshold for AAA surgery needs to weigh up risk of rupture in the next few months with risk of intervention and resource limitation. >7cm or imminent rupture AAA currently is recommended. 

Urgent/emergency vascular surgery

On call arrangements:  A second on-call consultant is advisable to help with both the emergency workload (and also if self-isolation becomes common). A vascular consultant surgeon should be on call and available to see all referrals. Trusts should consider having another vascular surgeon on call for delivering the surgery. 

Investigations 

Emergencies are likely to need a CT angiogram and proceed to surgery as appropriate. 

AAA: Ruptured aneurysms should ideally be treated by EVAR whenever possible to reduce dependence on the High Dependency Unit and reduce length of stay. Open surgery should only be considered when EVAR is inappropriate or unavailable and in cases where there is a good chance of success. ITU capacity will need to be considered prior to intervention. 

Critical leg ischemia / diabetic foot: Those legs immediately threatened require urgent intervention. Others may be diverted to a hot foot clinic for further assessment. Interventional radiological approaches may allow more appropriate utilisation of scarce high dependency beds. There may be situations where primary amputation may be more appropriate than complex revascularisations, multiple debridements and potential prolonged hospital stay.

Carotids: Crescendo TIAs would normally need urgent surgery. If there are severe resource limitations, aggressive best medical therapy more appropriate for recently symptomatic carotids.  

Spoke hospitals

Spoke hospitals allow patients to be cared for outside the hub. Currently, vascular surgical input is in the form of ward referrals, venous work, outpatient clinics, and angioplasties. These activities will need to be reviewed. There will need to be local flexibility, the but inpatient ward reviews, possibly in a virtual fashion may be appropriate. 

 Trainees

Surgeons in training will have keys roles to play in this crisis but the underlying principles of appropriate supervision, working practices, rest and pastoral care remain.