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‘Desperate times require desperate measures,’ maiden SVS Town Hall hears

BY BRYAN KAY

The contentious issue of the limited availability of personal protective equipment (PPE), and what this means for performing procedures, was given a robust airing during the first Society for Vascular Surgery (SVS) Town Hall, which focused on the early experiences of COVID-19.

Some of the most forceful arguments were delivered by Benjamin W. Starnes, MD, professor and chief in the division of vascular surgery at the University of Washington, Seattle, who drew on a surgical example to highlight why vascular specialists needed to carefully consider what procedures they were going to perform.

His colleague, professor and associate chief Niten Singh, MD, received a patient with a ruptured aneurysm who required open repair, Starnes explained. Afterward, the patient’s left colon died following which further procedures were required, culminating in a myocardial infarction and the placement of a coronary stent—and now palliative care. Multiple providers were in contact with the patient throughout the hospital, Starnes said.

“We can’t do these types of operations,” he continued. “We’re doing the emergencies the best we can. But we have got to get the picture here, and that is conserve PPE.”

The Town Hall panel, convened on March 27, consisted of an experienced group of vascular surgery leaders, and was co-moderated by SVS president Kim Hodgson, chair of the division of vascular surgery at Southern Illinois University School of Medicine in Springfield, Illinois, and Alan Lumsden, MD, the medical director of Houston Methodist DeBakey Heart & Vascular Center in Houston. Starnes has been at the vanguard of the vascular response to COVID-19, operating in, as Hodgson described Washington state, North America’s “ground zero” for the virus.

“We all have this sense of denial,” said Lumsden, responding to the picture painted by Starnes. “Once you’re in the middle of it, you get it. But trying to communicate what you’re communicating right now to people who are on that early phase of the curve— we all hope we’re not going to get where you are—but the reality is you’re right; we need to start conserving [PPE] now.”

In practice

Starnes elaborated on his team’s current practice as part of an answer to a question from Lumsden on what is done when confronted with a case of deep vein thrombosis (DVT), the incidence of which, the DeBakey chief noted, appears to have increased.

“In terms of our hybrid operating room, we’re trying to reserve it unless it’s absolutely needed,” he said. “We will try to use other operating rooms for any of these procedures. Last week, we had an open repair of a ruptured AAA and a gunshot wound to a carotid. Those were easy to do in a different operating room and reserve the hybrid operating room.”

Lumsden asked whether Starnes had been using a portable C-arm in such non-hybrid settings.

“We haven’t been operating,” Starnes said. “We have canceled probably two dozen complex aortic cases in the last month. We are following those cases, by the way—not only the aneurysm cases but the critical limb-threatening ischemia patients. We’re going to find out who loses a life and who loses a leg. These are desperate times, and desperate times call for desperate measures.”

The panel were posed the question of what vascular-specific complications surgeons were seeing in light of COVID-19. Starnes highlighted DVT: “Some of these patients are hypercoagulable and they’re developing DVTs—and they need to be treated with anticoagulation. But that causes an issue with all of the ultrasound techs in your lab who are going to be doing these DVT studies. That’s the only vascular complication of COVID infection that I’m aware of.”

New York

New York soon became the epicenter of COVID-19 in the U.S. Darren B. Schneider, MD, chief of vascular and endovascular surgery at Weill Cornell Medical College and director of the Center for Vascular and Endovascular Surgery at New York Presbyterian Hospital in the city, joined the Town Hall panel to provide a snapshot of the frontlines. He said his team had implemented much the same protocol as Starnes described in Seattle.

“For more than a week we haven’t done any elective cases, not even so-called urgent elective, and it’s only true emergencies that are life or limb threatening that we’re doing,” Schneider explained. “We have completely closed our vascular lab—no inpatient or outpatient vascular lab studies.”

The role of vascular surgeons in his hospital are shifting, Schneider continued. “Because we have to preserve PPE, facilitate physical and social distancing in order to try to the blunt the epidemic, which is out of control in New York.

“Our role is only to provide essential vascular services and now we’re being tapped for other roles. At one of our peripheral hospitals, one of the faculty members is now working in the ICU [intensive care unit] as an intensivist because they have a shortage and all their ICUs are full.”

SVS president Hodgson, meanwhile, highlighted a suggestion from China to limit vascular labs to one room when they can’t be carried out bedside, saying: “What are you doing to clean that room after each case?”

To which Lumsden responded by raising the point of the environmental services responsible for cleaning imaging, hybrid and operating rooms. “They are really put out to task at the moment— that’s one of the reasons we’re going to try to avoid using our hybrid room if at all possible and switch over to a regular room,” he said.

The panel also included SVS president-elect Ronald L. Dalman, MD, professor and chairman of vascular surgery at Stanford University School of Medicine in Stanford, California, who addressed the re-usability of N95 masks. “There’s a couple of different proposals,” he said.

“There’s a heat-based proposal and the other is more of a disinfectant … we’re doing some work right now to see if we can validate some of those recommendations. I think the one that is thought to be most effective right now is heat-based. I’m not recommending anybody do this but there is a potential for exposing it to heat or steam or some other form of heating that may allow for reutilization of N95 masks.”

The other panel members were Thomas Forbes, MD, chairman and professor of vascular surgery at the University of Toronto, Canada, and Daniel McDevitt, MD, president and CEO of Peachtree Vascular Specialists in Atlanta.