March 20, 2020
Vascular Society of Great Britain and Ireland Provides Guidelines for Managing Treatment Amid COVID-19 Pandemic
March 20, 2020—Professor Chris Imray, MD, President of the Vascular Society of Great Britain and Ireland, announced guidelines from the society to address the rapidly evolving situation regarding the COVID-19 virus as it impacts patients and the particular challenges for health care workers. These guidelines take into account current recommendations, but the situation is highly likely to change, noted Prof. Imray.
Additionally, the announcement advised that the Vascular Society, along with the National Health Service (NHS) Getting It Right the First Time program and the Specialist Commissioners, contributed advice to NHS England on the management of vascular patients in the current circumstances. This advice will be published shortly.
The guidelines, available online here, address treatment of abdominal aortic aneurysm (AAA), carotid artery disease and critical limb ischemia/diabetic foot, as well as urgent versus elective surgery, treating in an outpatient setting, and the use of spoke versus hub hospitals.
The demographic factors affecting greater risk from COVID-19 infection are highly pertinent to vascular patients. Patients at greater risk of infection include men, the elderly, the immunocompromised, those with ischemic heart disease, and smokers.
Prof. Imray stressed that health care providers must continue to focus on prioritization according to a patient’s individual need, but also must accept that hospital circumstances have changed, and this may impact clinical decision-making. Principles include reducing unnecessary exposure to hospitals, deferring less urgent cases, and reducing lengths of stay or dependency on intensive treatment units.
If the spread of the virus follows that in other countries, some very difficult decisions will need to be made. Local solutions are likely to be most important, but the Vascular Society will offer support and can be contacted by email, stated Prof. Imray
The aim of this document is to give general principles rather than absolute advice, noting that local decision-making is key. The guidelines include the following:
- Vascular surgery: Most arterial surgery is either urgent or emergency in nature and should continue at present when possible.
- Outpatients: When possible, only urgent outpatients should be seen, and virtual clinics should be considered. On discharge, many vascular patients will either need no outpatient follow-up (but be given a contact in case of problems) or can be reviewed in remote outpatient clinics.
- 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 the risk of rupture in the next few months versus the risk of intervention and resource limitation. Intervention for AAA size > 7 cm or with imminent rupture is currently recommended.
- 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. Intensive treatment unit capacity will need to be considered prior to intervention.
- Critical leg ischemia and diabetic foot: Those legs immediately threatened require urgent intervention. Others may be diverted to a hot foot clinic for further assessment. Interventional radiology approaches may allow more appropriate use of scarce high-dependency beds. There may be situations where primary amputation may be more appropriate than complex revascularizations, multiple debridements, and potential prolonged hospital stay.
- Carotids: Crescendo transient ischemic attacks would normally need urgent surgery. If there are severe resource limitations, aggressive best medical therapy is more appropriate for recently symptomatic carotids.
- Urgent/emergency vascular surgery and on-call arrangements: A second on-call consultant is advisable to help with 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.
- Emergencies are likely to need a CT angiogram and proceed to surgery as appropriate.
- 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, but inpatient ward reviews, possibly in a virtual fashion, may be appropriate.
A document from NHS England about supporting doctors in the event of a COVID19 epidemic is available here.
NHS coronavirus guidance for clinicians and NHS managers is available on the NHS website here.
Colleagues at all levels will need to consider how they can contribute within their competencies and current general medical council guidance.
The Royal College of Surgeons’ Coronavirus Action Plan is available online here.