 Welcome to the Texas Heart Institute Educational Programs. I'm Zvon Rekrazier. I'm an international cardiologist at Texas Heart Institute and CHI Health, Baylor St. Luke's Medical Center. Joining me today for this program on peripheral vascular medicine in the time of COVID-19 pandemic is Dr. Miguel Montero Baker. Dr. Miguel Montero Baker is an associate professor of vascular surgery at Baylor College of Medicine, and divisional chief of vascular surgery at Baylor St. Luke's Medical Center here in Houston, Texas. Welcome, Dr. Miguel Montero Baker. It's a pleasure to be here, Dr. Kreischer. Obviously, given the times, as you can see in the background, we're maintaining social distance. And so we're doing this remotely today, unfortunately, not together as we've done in the past. Thank you very much. So both of us are involved in treating of patients with peripheral vascular disease. You are a vascular surgeon, properly and extensively trained in surgery and also endovascular mode of therapy. We all know that there are significant destructive effects of COVID-19 pandemic on health care services. COVID-19 is a new pandemic with enormous impact on the hospitals, specialties, intensive care units, and also equipment. Peripheral vascular medicine is no exception as far as labs and operating rooms are concerned. Our goal is to improve safety of our patients and staff. And we have, for that particular reason, changed our mindset. We reorganized our patient flow as well as procedural steps and implementing new restrictive measures when and how we perform these procedures. If at all possible, these measures should be implemented before the worst of the major outbreak of this pandemic occurs in our community. So Miguel, if you don't mind, what is your practice doing to care of these patients? And also, what are your overall thoughts when facing such a difficult enemy? Like, I think the obvious danger is clear and present. It's always hard when you're trying to battle something that you can't see. But we all have well understood this for many years. And we had already been trying to take the initiative for a while of pushing telemedicine as different states throughout the United States have approved billing and coding specifically made and designed for telemedicine. We'd already started, but this has really projected us forward. One of the major things that we've had to do is embrace technology, understand how technology works and understand how we can better provide for patients in a remote way. And then the second thing that we had to do was create some sort of differentiation of acuity and then obviously communicate not only to our internal team but then to our external teams how we would go about deciding which patients come in and which patients could not come in. And of course, that would be something that we later would explain to our patients. So it's been a difficult process and we've had to just put ourselves in hyperdrive to get it as quickly as possible rolled out and explain to our patients, which unfortunately, given the age bracket in which they fall, not all of them are comfortable with this sort of modality of care. So what is your overall thought process when you approach your patients or for the last disease doing this pandemic? So in essence, really, we're limiting ourselves to only patients that have acute or serious subacute things. We're trying to explain to the patients that we're gonna have to do everything as an outpatient as much as possible, try to limit their contact. And on top of that, if there's any way that we can deliver care, which is non-hospital based, then that's also something that we consider. Also overall, our thought process is anything that could lead to the improvement of care and or limiting any reinterventions that patients may have has to be considered. And I mean, with that specifics, like the utilization of ultrasound, not only for access, but also for closure on these patients and certainly the embracement of telemedicine to keep tracks on the patients in the perioperative period, pre and postoperative from their care. So what is your thinking and reasoning when you say ideally, those procedures should be performed in outpatient setting? What do you have in mind? Why is that so important? Well, what we're trying to do, if you think about the patient's journey, when they get a procedure, they have to come in, they have to check in at a certain office, they interact with multiple of the employees and they go to another area where they get crept and draped. Then eventually they come to the cath lab and then eventually they get sent home. The interactions throughout the hospital are multiple. And we're talking about a hospital that right now has an ICU that's probably full with a lot of COVID positive patients. So we're trying to limit the amount of time the patient is and remains in the care of the hospital. And another thing that has been rolled out now for a while is office-based care. A lot of these procedures, even in acute and in acute and subacute settings, can be done as an outpatient in office-based labs that are certified. So that's where I'm going with this sort of message. Limit the amount of time that the patient has to interact with so many people within the hospital because all of these moments of interactions are moments that transmission of the COVID virus can happen. So we're trying to limit the amount of time the patient is inside the hospital and if possible, and we can give care the way we have said already some office-based cath labs, we actually try to do that in that way and not in the hospital. Yeah, thank you for explaining this. I absolutely share that your views regarding this outpatient activities for patient care. It basically follows the philosophy and make it as simple as possible, but not simpler. Now, another important thing is your last statement on this slide is the use of ultrasound for access. And I think it's extremely, extremely important. You might want to elaborate a little bit more because I believe that you are aiming this towards avoiding complications that could lead to surgery and hospital admissions. Is that correct? Absolutely, I'd say that in the era of endovascular therapy, knowing that majority of the cases that we have, we can do in this fashion, I mean in the minimally invasive, then the majority of the complications that we have that are not intraoperative and that we can't identify and treat are those that happen in the in the access site. And so, and this is, I would say probably the main cause of readmission of a lot of these patients is coming back for growing complications and that could be something as simple as a hematoma or it could be something like a pseudoaneurysm, for example. And so the more we do anything to limit the amount of complications, the better. Ultrasound has shown already in multiple studies, I mean, there's meta-analysis published showing that the limitation of complications by just adding ultrasound to access, identifying the structure allows you to have a safer procedure. But even more so, we're now at the moment where we're actually demanding our fellows to close growing under ultrasound guidance. So, for example, deploying a closure device, you can deploy the closure device and see every virtually every step of the deployment in closure deployment. And then moreover, you can actually make sure that with color, you don't have any extra vocation of flow immediately. So you're really cutting a lot of a lot on the risk and minimizing the possibility of that patient having any problems. I absolutely agree with you. I think this is very important, not for only for vascular surgery, but for all the specialists involved in end of vascular intervention. So those of you that have not embraced this technology and technique should learn this because this is the time when we have to do our best to avoid complications. And Miguel, I'm sure you share my views that this is not only true for femoral access whether it's retrograde or anti-grade, but for all accesses, right? Yeah, I mean, we're talking about radial access. We're talking about petal access for interventions. Brachial access when needed, it really is really a safety net and one should embrace it. And there's so many ways to get educated even in a remote fashion now and how to handle ultrasound and how to identify. And so that's something that people should keep an eye on. Thank you. So another very, very important question is which procedures are considered elective and which procedures are considered emergent? Of course, this is a very difficult question to answer because it depends on many scenarios. I mean, it might be different in certain areas like the New York or Italy or any other place where you have a tremendous burden and impact of COVID-19 on the hospital environment. And it might be different in certain areas where there is almost no impact or minimal impact. So this scenario, I believe is changing and it depends on many, many variables. But there are, I believe, some general guidelines. I'm sure a lot of societies, including SVS, established certain recommendations that should be implemented in the COVID-19 pandemic. Correct, ACC, SVS, many of our societies have come out. I am going to share, however, our local algorithm. We had a meeting together, all the division of vascular surgery and endovascular surgery, approximately a month and a half ago when we knew we were definitely going to get hit. And it was very obvious that we had to get something together. And of course, please understand this is not black and white. These are elements that need to be addressed on a patient-to-patient basis and elements that need to be determined based on different patient scenarios. But overall, this is what we think. Patients that should require care within hours are those that have traumatic vessel injury with hemorrhage and oreschemia. Patients that have uncontrollable bleeding from an axis site, from a bypass creation, or from a fistula or graft. Patients that have ruptured aortic aneurysms. Patients that have aortic dissections with rupture or with severe organ malprofusion. Aortic and aorta enteric fistulas with septic hemorrhage shock or signs of impending rupture. Acute mesenteric ischemia and SPS classification of acute limb ischemia. Just type 2A and 2B, especially in those patients that are on ECMO because they're so difficult to decide where they fall. Sometimes they're intubated too, but 2A, 2B is a safe way. This is an SPS classification and pretty much what it limits itself to are those that already have motor and sensory dysfunction. That translates a very acute and aggressive state of ischemia of a limb and that it's associated with limb loss if not intervened. So let me ask you this question. What would be your recommendation to perform whenever possible surgical correction of those multiple problems or endovascular? Which one would be your priority? Considering COVID-19, PPE, exposure risk and everything else? Yeah, I think that Dr. Kreischer, quite frankly, we cannot exclude ourselves as a variable within that thought process to that very good question. And I say that because in my, depending on my experience and my background, I may find very suitable ways to treat a lot of these patients in a more minimally invasive way. But I believe that other physicians may not necessarily feel that comfortable. So I think that you have to be very serious and look at what can possibly drain the system the most. So let's put an example. If we have a rupture AAA and you and I are very well obviously versed and comfortable in doing an open, I mean doing an endovascular repair, we know that we're going to drain the system less if we're able to do this in a minimally invasive way and safe way. I'm talking about less days in the ICU. I'm talking about less possibility of needing of transfusion in a time where blood is scarce. So I think that sort of decision has to be very serious and we have to put our thinking caps on. Maybe other more conservative physicians and surgeons may feel that under their scalpel, they may get those patients with less complications and off the table quicker. But I think one has to absolutely keep that in mind and do whatever will create the less impact on the system and move the patient along quicker. Now, one thing that was really sad what I've seen happening in other countries where this pandemic erupted and was in a situation where the physicians and experts especially couldn't provide the best medical care because they didn't have either equipment or facility to be able to do those procedures. So they were triaging the patient and taking into scenarios that some of those patients' lives could not be saved. I'm talking about patients that had a COVID infection and had one of those scenarios, whether it's a rupture of domiotic aneurysm or any other life-threatening situation where even without COVID, the mortality would be higher than 50% regardless of what you do. Now you have COVID on top of it and you have to make a decision. Fortunately, now we are not in that scenario. Correct, but you never know. I mean, I look at where New York is at right now and I think we just have to be mentally and emotionally ready if that type comes that those decisions may happen. Let's go down the list of now emergent procedures that should be done. We have those patients that we believe require care, but maybe not within hours, but still we don't believe these patients should be stopped from coming to the hospital. And those are patients I'll put on the top of the list of decanulations for ECMO patients, be that COVID or non-COVID. My team personally gets involved in a lot of these things and of course we have to take it very seriously when they're ready to come off ECMO. It's something that we need to do promptly, but maybe not within hours. It allows the entire team of care to align themselves and have everything we need. For example, when we need to do a decanulation bedside in the ICU, or is it better to maybe transport that patient to the OR? Right now we're doing that on a case-by-case of patients and deciding what limits the risk of the patient, but also of the healthcare providers in and around that care. Symptomatic carotids with stenosis greater than 50% deserve our attention within a day's period because they can lead obviously to ischemic insoles of the brain. Aneurysms that are above seven centimeters. Acute limb ischemia, rather for one or three. So in other words, the very mild ones that maybe has some mild case. It's not necessarily an urgency, but it may progress. So we have a few days to get that patient through or the patient that is actually completely far gone, the type three, which means that there's no motor function. There's no sensory function. This patient requires an amputation. That could be an hours thing depending on the patient's condition, but we've put it into the urgent meaning from one day to 14 days of a window to perform. Infected arterial prosthetics without overt sepsis or hemorrhage shock or impending rupture. Chronic mesenteric ischemia with significant weight loss greater than 20 pounds. Symptomatic renal vascular hypertension leading to acute renal failure. Massive symptomatically ephemeral DBT in a low-risk patient. And symptomatic venous TOS with acute occlusion and significant pain, discomfort and swelling of the upper extract. What about the exercise for dialysis? So as long as those don't, we're putting those in the ones that are semi-urgent in 30 days, I believe. As long as they're not leading to dysfunctional dialysis, we are not. So if we get a referral for somebody that requires, let's say now it's thrombosed, then those definitely go into the one to 14 days. Actually, probably on the more faster things unless they can get a catheter if we're planning on a new. But if we're just planning on a D-clot, we do them in the urgent scenario. And then this other slide is those that we believe need to happen. They start falling down because we know that some of these patients have months of having chronic ischemia. And now they've developed gangrene, but we know that that gangrene didn't develop overnight. Now, time is tissue, we understand that. I mean, our practice is very emphatically involved with limb salvage. But at the same time, we believe that somebody that has stable chronic limb threatened ischemia with stages two and three, meaning with some degree of tissue loss, we want to keep them close. We don't want to forget about them. We're not definitely going to push them for two or three months. But those may not necessarily have to run into the hospital. We do consider those that have a high degree of restenosis on some sort of a limb procedure or a bypass procedure that has a high risk of occlusion and then leading to acute limb ischemia. Those are the ones that we put in the semi-urgent list. Acute ileofemoral DVT in a very low risk patient, large asymptomatic visceral artery aneurysms. And then venous reflux with open complex active ulcers and infections. So what about the elective then? Yeah. So what we're doing really with this whole list is going to be patients that we obviously take the time to explain, let them know what's going on, why we're taking this decision. Because at the end of the day, we're doing this for their safety. I mean, all of these patients that have any degree of peripheral arterial disease are the perfect storm. If you think on their bodies to actually catch a COVID and have a bad result. So intermittent claudication, asymptomatic carotid stenosis, symptomatic varicose veins with clinically significant reflux, but no infection, no open ulcers. Dialysis acts as creation in a patient that is not already on dialysis or who has a functional line, an aneurysm below six centimeters, and then non-thrombotic, but symptomatic May-Thurner syndromes and thoracic outlet syndromes for chronic neuro or venous congestion without DVD. So those patients, we usually just say, hey, we're going to schedule your procedure. You may require an intervention, but this is something that we need to know where the health care system is going to be. Understanding that here in Texas, everything points to being May, anywhere between May 5 to May 15, our peak of health care utilization and overutilization. So we need to book at least those cases after the May 15 time when we can better reassess where our supply is going to be of care and opportunities. So how do you decide and how you triage your patients when they call your office? Who is being seen in an outpatient clinic and what are your guidelines and who is being evaluated using telemedicine? So we are, again, first of all, we did, there was a two-phase part. The first phase was we had all these patients already booked. And so the first stage of this was to comb through all the lists of patients and determine who really needed to come and who didn't. And in order to do that, I mean, we're talking about we had to reschedule over 500 appointments within less than three days. So we created these guidelines to extend to the mid-levels who helped us do this in a very successful way. And so anybody that was coming for surveillance purposes, we deferred. Anybody that didn't have any ongoing and acute issues, we deferred. For those that we thought required like an in-house visit were mainly those that were going to get some sort of imaging, required a CTA, a duplex scan or something because they had something of an acute nature. So symptomatic carotids with TIAs or hemispheric TIAs were those that were brought in. Aneurysms greater than six centimeters were those that we believed needed to be evaluated. Foot infection or gangrene, again, when they needed to come in for additional imaging, a wound infection after surgery, be that of a bypass or a carotid or a patch or even an angiogram from the access site, sudden onset of unilateral swelling that where there's a high degree of suspicion for a deep venous thrombosis. Those patients required to come in because they needed an ultrasound and clinically significant malfunction of an existing AVF or AV graph that required care because their dialysis was being insufficient or ineffective. Now, one caveat to all this is those patients that had, for example, all the imaging done and had the ability of getting telemedicine, then we would call and invite them to do telemedicine because that is the priority of care. And so, for example, thoracic outlet syndrome on the sudden onset of arm swelling, atypical limb or foot pain with normal AVIs or dialysis access, mapping and clinic visits of patients, all of that we immediately put into the realm of telemedicine. And it's been a lot of painful and suffering growth but I can tell you that today that I was in clinic in the morning, I had a podiatrist doing telemedicine where the patient was literally putting his foot on the camera. On the other side, I had a vascular surgeon doing telemedicine looking at a CT scan and explaining the options to the patient for the care for their AAA. And quite frankly, patients have been highly receptive because they're afraid. They don't want to come in. So they're actually being part of this process. It's a very transformative process that I think we're going to have to all go through. What are the changes that we have to make as far as international suites are concerned and also the operating rooms considering all the issues that we have to deal with COVID-19 pandemic? Well, first of all, communication. There was a lot of work going back and forth, getting everybody all the leadership in the right spot. We're talking about cath lab leadership. We're talking about CV, OR leadership. We're talking about ICU leadership, the designation of those areas that we're going to be COVID or non-COVID areas and then how we would move this around. And obviously, it's a long process that goes into much detail. But in essence, what we try to do is to perform procedures safely. And I'm saying safely for the patients but very safely for us. I mean, there is no way that nobody should put themselves as part of the first responders' teams, if you may, at any risk by not utilizing adequate protection. And if possible, only within the COVID environment area. So there are ORs dedicated for COVID patients. There are cath labs dedicated for COVID patients. And at the same time, there's units for ICU care that are dedicated to COVID patients only. I cannot stress this enough. All healthcare workers should be involved in procedures that educate them about using PPE adequately and that they know how to use it. And I will be very honest, I thought an N95 mask was just an N95 mask and it was used in the same way. And quite frankly, I went to the course and I was educated on a few little details of how to really put the nose part really tight and breathe only through my mouth. And there's a lot of little things that I was unaware before all this. So there's a lot of education that goes into it, a lot of fitting adequately the masks. It's not, you can't just grab any mask because you're going to be unprepared if you believe that just a normal mask is something that can protect you against COVID. Well, Miguel, I think we covered a lot of issues and I think it is very informative to hear from a vascular surgeon also how you deal with this issue. In an environment like ours, it is still not at the peak as far as epidemic is concerned, but we never know what might happen. And the most important thing is to be prepared to think ahead because it's always better to be proactive than retroactive. And you've been a dear friend. We've been working together on many different complex scenarios and I'm very appreciative of your expertise and your friendship. And I cannot thank you enough for your valuable contribution to this Texas Art Institute educational program on peripheral astro and medicine in the time of COVID-19. Thank you very much. It's an absolute pleasure, Dr. Crazier. Thank you for having me again. And I hope this was of use for all of you guys out there in the worldwide. Stay safe.