ISEVS Critical Issues II: Limb Salvage During a Pandemic

Examine arguments and seek solutions.
Host Alan B. Lumsden, MD (Houston Methodist), ISEVS President

Panel
Michael Lichtenberg, FESC (Chefarzt Klinik fur Angiologie)
Peter A. Schneider, MD (UCSF)
John Rundback, MD (Holy Name Medical Center)
Palma Shaw, MD (Upstate University Hospital), ISEVS Secretary
Andrew Klein, MD (Piedmont Healthcare)

​Proceedings

00:06:45-00:07:45 
[Alan Lumsden] Introduction of Purpose, "Examine the arguments, seek solutions." 

00:07:46-00:16:27 
[Palma Shaw] Review of the American College of Surgeons Guidelines to assist in triage of patient procedures; introduction of panelists 
Discussion on differences in the impact of these guidelines depending upon practice location and prevalence of covid-19; note contrast in infection control between US and Germany. 

• [Michael Lichtenberg] under control in Germany: mortality rate low, ahead of the USA in the situation and now considering re-opening
• Learned from Italy, France, and Spain: check resources first, and stop elective cases immediately
• Protect, prevent, decrease workload, increase staff and tech support
• 2,500 deaths Germany; in Plateau Phase at time of broadcast
•  reinstated triage; essential to invest in resources that increase ICU capacity
• Treating patients with CLTI, moving slowly towards normal 
• Hoping to schedule claudicants soon 

 

• [John Rundback] things still out of control in the NY metropolitan area
• Six weeks into it and predicts four weeks to go. 
• How to triage CLTI patients? 
• The 400-bed hospital is a 250 bed ICU 
• They are the line service 
• Has active eCLTI program; 
• In the hospital, most PAD work shut down- trying to preserve PPE 
• Resistance to admitting patients 
• Do safe interventions, temporize for later intervention. How do you follow patients? Doing weekly telehealth calls with established patients
• Office-Based – picking up, doing cases that cannot wait 
• How to follow the patients for intervention? Try to prevent something from going wrong. 

​00:16:28-00:27:00
How to follow the patients when they cannot come to the hospital? How can we prevent a semi-urgent case from turning into an emergency?
​The panel weighs in on what they are doing to connect with their patients: implementation is complicated and dependent on patient access to and familiarity with audiovisual technology.

• [P. Schneider] use of Telemedicine previously in Hawaii. 
• Telemedicine is unsatisfactory if a patient needs triage, although it works well for recovering patients.

 

• [M. Lichtenberg] patients Rutherford 4 in Germany were treated during pandemic, and send home ASAP 
• Several patients are arriving too late. A wave of patients will be coming in worse. 

 

• [J. Rundback] 3 groups of patients: established and effective communicators; ill and elderly without tech fluency; new patients referred by PCPs, podiatrists some or Wound Care centers- trying to help those that they can 
• Comment on the use of OBL- using up PPE vs. off-loading hospital volume; be judicious. What price is PPE per limb loss?
• The risk to patients coming in who are at risk of getting COVID19 ​

Question from the audience

Are you testing CLI patients for covid antibodies before urgent endovascular procedures?

00:27:01-00:29:16 
Discussion regarding the use of testing in the reintroduction of procedures

• [M. Lichtenberg] screening for symptoms and only testing febrile patients for covid antibodies; all patients with covid symptoms redirected to a facility with specialized units; highlights apprehension in patients to seek medical care from fear of covid-19. 

00:29:17-00:35:39 
[P. Schneider] Differences in response across panelist locations?
​

• [Andrew Klein] The recent introduction in Atlanta, Georgia, of a new wing to help capacity for COVID with 200 new ICU beds; currently staffing for an anticipated surge in late April
• Patients sitting at home and avoid coming in
• ICUs run by Cardiology in many New York sites; cross-training staff 

 

• [P. Shaw] At Syracuse, prohibitions on CLTI patient operations, sending staff to nearby centers to help. Has many patients hours away in rural areas and expresses concern.

00:35:40-00:39:00
Reintroduction of patients in Germany vs. US

• [M. Lichtenberg] process is contextual and driven by resource availability. Anticipates surge in patients in May and June; solutions are driven by resource-availability and not generalizable. 

 

• [A. Klein] limiting in-hospital staff in Georgia, some redeployed to other units in the hospital. There are daily adjustments to best balance, minimizing exposure and development of complications. 

00:39:01-00:46:44
POLL: I am currently doing procedures for CLTI only (100%) claudication only (0%) CLTI and claudication (0%)

POLL: The pandemic has changed the type of procedures I would offer to a patient with critical limb ischemia.
RESULT: 81% True, 19% False

• [P. Schneider] describes a sliding scale-we want to minimize resource utilization which promotes interventions that are resource- and cost-efficient despite lesser long-term patency;
• would delay complex bypasses with endovascular options. 
• Discussion regarding the different impacts of institutional policies during a pandemic as it affects the ability to treat. 

 

• [P. Shaw] colleagues have had to do above-the-knee amputation in patients who needed a distal bypass prohibited by the administration

POLL: I have changed the location of where I practice critical limb interventions.
RESULT: 33% True, 67% False

• makes sense to have an added incentive for OBLs
• minimize risk during interventions: anticoagulants

POLL: I expect to return to at least 50% of my pre-pandemic practice within 2-4 weeks (7%) 4-8 weeks (50%) 8-12 (29%) >12 (14%)

POLL: My use of duplex ultrasound testing is same as precovid (20%) very selective (60%) emergent/urgent only (20%)

POLL If you opt to follow-up with a patient with CLI, how do you provide ongoing evaluation? Office visits (41%) Facetime at home (18%) Through my EMR telemedicine application (35%) Tell patient to contact me if it gets worse (6%)


00:59:00-01:02:36 
Covid-Related Vascular Issues: Hypercoagulability
VTE Management discussion.
Thrombotic events and management, prevention 

• [J. Rundback] substantial increase in DVT/PE intervention that is creating problems for techs who follow the patients COVID
• Patients clot and bleed; following BTK; foresees an explosion in patients and limited access to catheter-based therapy
• Use of LMWH rather than heparin drip 
• Increased procoagulant state 

1:02:37-1:07:20 [A. Lumsden] Case scenarios 

• Rapid decompensation: pt is a young covid+ female, dx with bilateral DVTs then developed a PE while on aggressive IV-directed anticoagulation tx
• [J. Rundback] [M. Lichtenberg] these are per-team decisions; they would opt to put on ECMO first to support ventricle followed by mechanical thrombectomy.

 

• Lysis in the lower extremity for ischemia: use lytics?
• [M. Lichtenberg] would not use lytics in covid+ pt, would use mechanical or aspiration thrombectomy; pts too at risk for dramatic bleeding complications. 

 

• Consensus on lytics as a last resort
• Discussion regarding algorithms for patient management (distal bypass, toe amputation, wound management)

Question from the audience

I think we should discuss strategies coming out of this pandemic, as patients are absolutely petrified of coming to any medical institution. See Tim Henry's paper. STEMIs are 44% down. Patients stay home with chest pain."

1:07:21-1:13:00 
Consensus: The strategy now is different from our usual routine . Talk to the patients, reassure them, educate them
Discussion regarding re-initiating procedures and getting people to be willing to come into the hospital 

• [M. Lichtenberg] 35% less admission in MI/stroke in recent weeks; this means pt stays at home out of fear that going to a hospital will give them a life-threatening respiratory infection. There are German PSAs/media campaigns designed to guide patients to care. "Don't let covid be responsible for your amputation" messages are published in newspapers and social media. 

 

• [P. Schneider] Treat the whole patient. Doctors have to meet patients where they are, and address/alleviate their fears. Elucidate the things HCPs are doing to protect them.

 

• [A. Lumsden] Has Germany seen patient site-of-service-selection migrate due to reported covid prevalence between hospitals? 
• [M. Lichtenberg] Yes. Germany has small, one-building hospitals that, once affected, are shut down and therefore bypassed by referral pathways. It is essential to organize information systems how the individual hospital has a problem with covid or not, what is the hospital doing to protect? Some countries in Europe have this system where much information is available on individual hospitals. ​

1:13:01-1:15:14 
[A. Lumsden] Why was the USA west coast affected differently? 

• [P. Schneider] difficult to say, although there is a wide-open exchange between China and the west coast. They likely had cases early on, so why didn't it take hold? Santa Clara County and Seattle had identical early trajectories. The former did a very early shelter-in-place order in the Bay Area. Wonders if communication between China and Silicon Valley played a preparatory role.

Question from the audience

Options for revascularization - use of prosthetic vs. vein? Endovascular over open now in this era? How to decide what to do?" 

1:15:15-1:21:09

• [P. Schneider] does not affect his decision making; any more distal vein graft is the better choice. Endovascular is more favorable than operations currently; avoid increasing complexity. Open operations should have a long shelf-life.

1:21:10-1:29:30
Consensus: We will come out of this smarter. TEAM spirit has been remarkable, turf wars subside, decision-making expedites

• Vascular teams avoiding getting together, use video communications, keep people (vascular interventionalists) out of the hospital. 
• Outside of hospital communication with the patients- telemedicine here to stay 
• Telemedicine will help treat more remote patients; Virtual ICUs
• Opportunities to build team cohesion between physicians and administrations. It is crucial to have a covid command center and coordinate across departments, roles, and responsibilities.
• How to detect COVID coming forward? Testing? How to get back to business as usual, especially in tertiary centers.  ​
• What about trainees? How will this loss of interventional opportunities impact them?