Dr Arvind Kohli
The novel coronavirus-19 (COVID-19) disease pandemic represents the largest and fastest moving challenge to the world’s public health and health care systems. As the impact of Covid 19 spread, health care systems around the world are responding with large-scale protective measures and reallocation of resources Vascular surgical care is considered one of the necessary/urgent hospital surgical services in this critical time and the role of Vascular Surgeons is broughtforth to join efforts to combat this infection and possibly save patients in a dire situation.
Challenges of vascular surgery. The vascular patient due to its nature associating several comorbid states should be considered at higher risk when compared with other populations. Vascular surgery communities have tried to stratify patients into those requiring urgent care during this pandemic situation, that is, large abdominal aortic aneurysms or ruptured abdominal aortic aneurysms, critical limb ischemia (CLI), and symptomatic carotid disease and. Venous Thromboembolism manifesting as Pulmonary Embolism (PE)
PE is a potentially lethal form of venous thromboembolism wherein a blood clot arising from peripheral veins migrates to the Lungs and becomes a rather challenging situation to manage The number of diagnosed PE cases have been continually increasing, It is already described that disseminated intravascular coagulation can occur in patients with severe COVID-19 leading to Septic PulmonaryEmbolism(SPE). COVID-19-related SPE is a lethal complication and a negative prognostic factor.
Besides anticoagulation, PE treatment consists of systemic fibrinolysis (SF), catheter-directed thrombolysis (CDT), and surgical thrombectomy (STE). SF shows both a high survival rate and significant bleeding risk for stable PE patients. SF is recommended in high-risk patients and in deteriorating patients.
STE is recommended in high-risk PE patients with contraindications for SF or when SF has already failed. CDT (including aspirational thrombectomy) seems to have more benefits than risks for the patient compared to STE and it is considered an alternative to STE when there is contraindication for SF or when SF has failed.
Anticoagulation and SystemicFibrinolysis can be performed by Internists attending to these patients however, the two methods used in PE patients SurgicalThromboembolectomy and CDT-could be performed by vascular surgeons. In patients with COVID-19, any CDT technique could be of great clinical benefit because it improves pulmonary circulation without the risks of SF or STE.
Most CDT techniques are performed in existing setups of specialized centers by multidisciplinary PE response teams consisting of cardiologists, interventional radiologists, vascular surgeons, intensive care physicians, and pulmonary specialists. These teams rapidly evaluate the frail or quickly deteriorating patient, then choose the optimal technique for maximum patient benefit and finally execute the plan.
Vascular Access for Chronic Kidney disease
Dialysis demand in India is growing at a rate of 31 per cent, compared to six per cent in the United States and eight per cent in the rest of the world.Keeping in view the high number of patients who require hemodialysis,the vascular surgeons come in front by providing the much needed Hemodialysis vascular access(HVA) in form of hemodialysis catheters and AV fistula surgeries even in this Covid 19 Era
Critical Limb Ischemia Critical lower extremity ischemia (CLI) is a common vascular emergency. The etiology of ALI can be multifactorial, with thrombotic occlusion generally occurring in the setting of a previously treated arterial segment or associated with atherosclerotic arterial disease. A recent analysis of a large database showed the relationship between COVID-19 infection and hypercoagulability in preliminary observations Patients with hypercoagulable states are known to have a risk of native arterial thrombosis, one of the most challenging of ALI scenarios to treat. and Vascular Surgeon is called out to perform Emergency interventions like Thromboembolectomy or Heparin or Prostaglandin infusions need to be done for managing these conditions
ECMO or Other Hemodynamic Support for COVID-19 Patients
Cardiovascular Specialists are called in some of the most severe COVID cases to help with extracorporeal membrane oxygenation (ECMO) therapy when patients become extremely hypoxic or their lungs are no longer functioning. Other types of hemodynamic support, including Impella Device (Right Heart Bypass) and intra-aortic balloon pumps (IABP), also have been used to support COVID patients in cardiogenic shock, in cases of left or right COVID-induced heart failure or multi-organ failure.
COVID-19 can predispose to venous and arterial thromboembolic diseases due to excessive inflammation, hypoxia, immobilization and DIC. Therefore, there is a need for risk stratification for VenousThromboembolic and Arterial Events for all hospitalized patients For Prevention Thromboprophylaxis is necessary during the hospitalization of patients with COVID-19, unless there is a contraindication, the choice and duration of therapy varying according to the patient’s clinical situation and the protocol established in the hospital unit, and based on the guidelines of the Hemostasis and Thrombosis Societies
The COVID-19 pandemic has resulted in change in the management strategies by the healthcare authorities, including a shift to operating only for urgent and emergent indications. This has led to many untreated vascular patients, the effect of which has yet to be determined.However the Vascular surgeons are standing upright along with other Covid Warriors in tackling all those conditions arising out of Covid 19 pandemic.
(The author is CTVS Consultant GMC Jammu)
Dr Arvind Kohli