Aortic Disease in the Time of COVID: Repercussions on Patient Care at an Academic Aortic Center

Abstract

The novel coronavirus disease 2019 (COVID-19) has imposed a severe strain on healthcare systems worldwide and is now impacting all hospitals in the United States. 1 As of this writing in early April 2020, most large medical centers in the US have either restricted or completely cancelled elective surgical procedures, including cardiovascular procedures. A recent survey of vascular surgery practices around the world found that most have significantly scaled back elective surgery in the face of the pandemic. 2 We have addressed these challenges by modifying our surgical indications and work flow to accommodate the constraints of this new environment while continuing to provide appropriate and timely surgical care for patients with aortic disease. Here we describe the modifications we have implemented in clinical care provided by the multidisciplinary Aortic Disease Program at our large regional referral institution to address the challenges presented by the COVID-19 pandemic. Clinical Repercussions of COVID-19 Numerous reports have documented the deleterious effects of COVID-19 on the myocardium, possibly related to the significant inflammatory response generated by the viral infection.3, 4, 5, 6 Data on the implications of this phenomenon in aortic disease are lacking. Aortic inflammation has been shown to play a role in aneurysm progression, 7 so it is theoretically possible that COVID-19 may worsen aortic disease or cause increased aortic complications. More data are needed to evaluate this question as patients with concomitant COVID-19 and aortic disease are identified and followed. Unfortunately given the rapid escalation of this worldwide pandemic, we do not have the luxury of waiting for definitive data regarding the effects of COVID-19 on the cardiovascular system—we must proceed in the face of this uncertainty to continue to take care of patients. 8 National and International Guidelines on the Timing of Cardiovascular Procedures Multiple professional societies have issued guidance for cardiovascular and surgical specialists in the face of this crisis. The American College of Cardiology has recommended that all elective cardiac catheterization procedures be postponed and has modified recommendations for emergency situations such as myocardial infarction. 9 The Chinese Cardiovascular Society issued guidelines recommending that control of the epidemic was the top priority, even in the face of acute presentation of cardiovascular disease patients. 10 The American College of Surgeons issued guidelines for elective surgery with the recommendation that aortic aneurysm patients without complications could be postponed. 11 The Centers for Medicare and Medicaid Services published a guidance document on March 19, 2020 detailing a three-tiered priority framework for postponement of elective surgical procedures. 12 Our hospital’s OR executive committee directed all surgical services to cancel elective procedures for patients with upper respiratory symptoms effective on March 12, 2020. This guidance was expanded to mandate rescheduling of all elective procedures starting on March 16, 2020. Local Approach to Surgical Criteria and Operative Intervention While these broad government and hospital system guidelines have been helpful to provide context for the discussion, the faculty of the Aortic Disease Program aimed to develop a more specific approach for our patients. As such, we have implemented modifications to our surgical criteria for patients who otherwise meet indications for operative intervention. This decision has been informed by both our internal discussions and the Society of Vascular Surgery Guidelines (Figure 1 ). 13 Most patients with isolated descending thoracic or abdominal aortic aneurysms less than 6.5 cm and root, ascending or arch aneurysms less than 6.0 cm have been postponed until the surge has passed, which we anticipate will be in 2-3 months. Patients with both proximal aortic aneurysms (root, ascending, or arch) aneurysms and coronary artery disease or valve disease are being considered on a case-by-case basis. Symptomatic aortic stenosis with concomitant aortic aneurysm is classified as time-sensitive and we have proceeded with these procedures. Patients with subacute or chronic Type B aortic dissections who otherwise meet our criteria for TEVAR have similarly been delayed until after the surge passes. The locoregional impact of COVID-19 should be considered as each hospital system and aortic surgery practice develops an individualized approach to prioritization of scheduling. Clearly, hospitals with higher burdens of COVID-19 patients will likely be forced to impose stricter restrictions on elective surgical scheduling. Figure 1 Society for Vascular Surgery recommendations for tiered approach to elective vascular surgical procedure scheduling. Ref. 13 HYPERLINK "https://vascular.org/news-advocacy/covid-19-resources" \l "Guidelines&Tools" \o "https://vascular.org/news-advocacy/covid-19-resources"https://vascular.org/news-advocacy/covid-19-resources#Guidelines&Tools Extent of Operation and Surgical Approach We have also considered altering our operative plan for patients with aortic disease in need of high-risk operations to take into consideration the current and projected constrained resources of our hospital system due to the pandemic. Should patients be temporized with an expeditious strategy of stabilization through endovascular repair rather than a definitive open repair to decrease the length of stay and preserve scarce hospital resources? Should an anticipated need for personal protective equipment (PPE), blood products, or prolonged intubation or ICU stay in this time of constraint play a role in decision making? We recently treated a patient who presented with a ruptured thoracoabdominal aneurysm by utilizing a temporizing TEVAR procedure rather than performing a more definitive, but more resource intensive, open repair. While we were able to achieve an adequate proximal seal in Zone 2 of the arch, we accepted a suboptimal distal landing zone within aneurysm thrombus in the supraceliac aorta (Figure 2 ). This approach stabilized the patient and reduced utilization of hospital resources. She was expeditiously discharged and we will perform the definitive repair once the surge of COVID-19 cases has abated. Figure 2 A 68 year-old woman with acute aortic syndrome, ruptured TAAA. Admission CTA axial (A) and coronal reconstructions (B). Post emergency TEVAR repair, (C) CTA coronal reconstruction demonstrating the suboptimal distal landing zone (arrows; endograft in aneurysm thrombus) and (D) 3D reconstruction demonstrating patent left common carotid to left subclavian bypass graft and good proximal seal in Zone 2. Personal Protective Measures in the Management of COVID-19 Patients with Aortic Disease A limited report from Wuhan, China documented successful surgical treatment of four patients with confirmed or suspected COVID-19 who presented with Type A aortic dissection. 14 The authors stressed the importance of N95 mask protection and multiple layers of gloves and gowns worn by the anesthesia team. These layers of personal protective equipment (PPE) were disinfected in between the pre-procedural steps of intubation and central line insertion. They also utilized video laryngoscopy to allow the anesthesia providers to maintain maximum distance between themselves and the patient’s oropharynx. Muscle relaxants and high-dose narcotics were administered before airway manipulation to minimize the risk of coughing and vomiting, which would aerosolize secretions and greatly increase the risk of virus transmission. They used tape to secure all seams in the PPE, including between the gloves and the gown and the mask and the goggles. These increased universal precautions should be utilized by the anesthesia team providing airway management for all patients requiring surgery who have known or suspected COVID-19. It is unclear whether this level of protection is necessary for the surgical team performing aortic surgery (after the airway manipulation portion of the procedure is completed), but increased precautions may be prudent for all members of the care team. Patient Decision Making While the burden of cancelling or postponing elective aortic surgery falls primarily on the surgeons, patients are also struggling with these difficult decisions. At least three patients who met our criteria for elective aneurysm repair have decided, following appropriate shared medical decision-making efforts, to postpone their operations until they become symptomatic or the surge has passed. Each patient needs endovascular repair of an abdominal aneurysm, two juxtarenal, but they are > 60 years old and have underlying medical co-morbidities. They have elected to assume the risk of an aortic complication to avoid the risk of contracting COVID-19. Additionally, our hospital has implemented strict no-visitor policies in an effort to reinforce social distancing and decrease spread of the virus. This does not factor significantly into the physician decision making but has been a critical component of patient decision making. Role of Telemedicine Increased use of telemedicine visits can reduce the exposure of patients to hospitals and clinics actively treating COVID-19 patients. CMS recently waived the HIPAA-compliance regulations for multiple video and voice platforms and allowed for provider and health system reimbursement for telemedicine visits, greatly facilitating the expansion of these processes. 15 Telemedicine is an ideal adjunct for clinical management of aortic disease, as these patients rarely have critical clinical decisions that rely on physical exam maneuvers that must be performed in person. We have transitioned the majority of our initial patient evaluations and routine surveillance clinic visits to the telemedicine platform. Routine post-operative visits are still being performed in person on a case-by-case basis, depending on the specific needs of each patient. Both patients and providers have appreciated this approach to minimize potential virus exposures while maintaining high quality clinical care. In fact, this may be one of the lasting impacts of the pandemic to clinical practice, particularly for patients who live far from a tertiary care center. Routine post-surgical follow-up or routine surveillance imaging can and is already often obtained locally but patients then drive 2-6 hours to be seen in person. Now that both patients and providers have experienced that this is not in fact necessary the likelihood of returning to the former practice model is low. Management of Pending Surgical Backlog and Hospital Capacity Treatment of patients whose elective surgery was postponed during the crisis will be an important consideration in the months following the peak surge in COVID-19 hospital resource utilization. The backlog of surgeries will cause a significant strain on operating room, intensive care, and hospital capacity that could result in further delays of surgical care. In addition, aortic surgery patients have a relatively high utilization of post-acute care in skilled nursing facilities and inpatient rehab centers. 16 These resources will likely be stressed by the coming influx of recovering COVID-19 patients, creating an impediment to discharge for patients following aortic surgery and further reducing hospital capacity. 17 The most prudent course of action will be institution and hospital-system specific, but all surgical practices will benefit from pursuing a deliberate approach to the period of post-COVID return to normalcy that we all hope to achieve. A recent report from an acute care surgical program describes a practical prioritization framework for addressing this challenge. 18 In our program, we have instituted a tiered prioritization model for all cardiovascular surgical patients, including patients with aortic disease. As new patients are referred or existing patients meet criteria for surgery, they are assigned a priority from 1 to 3 based on urgency and compiled into a master list. Given that our operating room block time is structured by service, the cardiac and vascular services have separate master lists. Our entire faculty meet (virtually) once a week to go over the list and agree upon prioritization of each patient in a rolling fashion so we can remain responsive to the changing hospital resource environment. While priority of disease is the most important factor determining each patient’s position in the queue, we are also taking into consideration the projected length of stay in the ICU and in the hospital for each patient following surgery. We are fortunate to have a large dedicated cardiovascular ICU, but the ICU service is limited by number of beds and staff. To prevent complete saturation of the ICU service (and the resultant inability to perform elective surgery), we plan to alternate scheduling of patients with projected longer ICU stays with patients expected to recover more quickly. This approach will preserve ICU throughput and allow the most efficient clearance of our patient backlog. The decision-making model will be different in each regional and institutional environment, but multi-disciplinary collaboration with social workers, the blood bank, supply chain, and hospital staffing will be critical. Efforts to “flatten the curve” are already showing effect (Figure 3 ). The intended consequence of these mitigation efforts is that the increase in COVID-19 patients will have a prolonged and lower peak. If this strategy is successful, many regions will continue to experience resource limitations, not just in the short term but for many months. An understanding of local modeling of disease burden and system resources will be critical as we continue to evaluate and re-evaluate our patients who are currently in limbo. Success in flattening the curve will also mean that the devastating choices faced by clinicians in areas where this did not occur may be avoided. At this time we do not anticipate the need to palliate patients who would otherwise be treated due to lack of beds, ventilators, or PPE. We are still on the “pre-peak” part of our curve and this decision will be assessed by the Aortic Program faculty as necessary. There is no algorithm per se as the inputs are changing constantly. However, the Vascular Surgery Activity Condition or VASCCON model put forth by Dr. Forbes can be implemented using understanding of local conditions. 19 We currently receive a daily report and there is a live dashboard with important institutional data including number of COVID patients, patients under investigation, PPE supply chain, ventilator and ICU bed status, and ECMO capacity. This type of transparency will be critical for any institutions considering loosening or restricting current surgical care. Figure 3 Projected COVID-19 case burden for the University of Utah Health system. A) The initial analysis projected a surge in cases in mid-May, but the revised “flattened” projection (released 3/31/20) anticipates a surge in cases in early June (B). Effects on surgical training As a teaching hospital, all of our training programs have been significantly impacted by the COVID-19 pandemic. Both our vascular and thoracic surgical fellows have been maintaining a clinical presence in the hospital for patient care and performing cases as usual. With the drastic reduction in elective case volume, our fellows have experienced a drop in their case volumes as well. While we are fortunate that we are a high-volume center and our graduating fellows have already met the case requirements for graduation, we have been emphasizing the importance of simulation lab practice time and have maintained open communication between the faculty and the fellows to maximize learning with each opportunity for a surgical case. We have cancelled all in-person meetings and didactic sessions, including education and morbidity and mortality conferences, which have all been moved to a video conferencing format. Given the sophistication of the software available, we have not experienced a drop off in conference participation or quality with this change. Interestingly, we have begun discussions among the faculty to consider keeping the virtual format indefinitely for some select conferences and education activities, as it can facilitate participation for fellows who are spread across multiple different hospitals rather than demanding in-person attendance. Conclusions These are uncertain times, and a balanced thoughtful approach is needed for management of patients with aortic disease. It is crucial that the international community of aortic specialists work together to achieve consensus on how best to prioritize appropriate patient care while preserving capacity of the healthcare system to address this crisis. The SVS is to be commended for developing clear guidelines surrounding this type of decision making. Ideally, all relevant societies would draft such guidelines in a collaborative consensus-building manner, both to minimize differences in regional decision making as well as to provide a “pandemic standard of care” to protect physicians across specialties from medicolegal liability for outcomes related to resource constrained decision-making. There may be a role for government intervention as well; New York State has recently passed legislation allowing for legal protection for physicians and hospital systems making difficult decisions in the face of the pandemic. Given the high morbidity and mortality for untreated acute aortic syndrome, it seems clear that surgical treatment should be offered whenever possible to these patients. Decision making for elective or urgent aortic surgery is much more nuanced and will be best served with an institution and program-specific approach. By taking these collective measures, we as a specialty can continue to provide the best possible care for our patients in the context of our new shared reality.