OEIS Procedural Conduct Recommendations during the COVID-19 Crisis of 2020

OEIS Members,

The new procedural recommendations are listed below. An expert panel convened and felt as of 4/5/2020 that these represented reasonable guidelines regarding what constituted elective vs non-elective procedures. We are seeking further guidance from state authorities in Florida but have not received official guidance as of yet. Each physician must make individual decisions regarding postponing/proceeding with procedures and what constitutes compliance with their state mandates.

NOTE: at the bottom of the table on this page is a button where you can download the new procedural recommendations in a printable format.

OEIS Procedural Conduct Recommendations during the COVID-19 Crisis of 2020

April 6, 2020

Peripheral Arterial Disease (PAD):
1. Risk of not proceeding if appropriate: acute limb ischemia, worsening wound, pain, bone infection, more extensive amputation, or limb loss which can progress to become life threatening, or loss of independence).
2. Procedures: angiography, angioplasty, atherectomy, stent placement.
3. Indications and recommendations:

POSTPONE	PROCEED
Rutherford 1-3 (claudication)	Rutherford 4 (ischemic rest pain): moderate to severe
Rutherford 4 (ischemic rest pain): mild	Rutherford 5 (progressive ischemic wounds)
	Rutherford 6 (wet gangrene)
	Distal embolization: with wounds or tissue loss
	Vascular Bypass and/or stent(s) with severe stenosis felt to be at risk of thrombosis

Abdominal aortic aneurysm (AAA) repair is performed in the hospital but is often preceded by planning or preparatory procedures such as embolization:
1. Risk of not proceeding if appropriate: aneurysm rupture and death.
2. Procedures: angiography, angioplasty, atherectomy, stent placement.
3. Indications and recommendation (these recommendations concern the outpatient planning or preparatory procedures only):

POSTPONE	PROCEED
Asymptomatic AAA less than 5.4 cm	Asymptomatic AAA greater than 5.4cm
	Asymptomatic AAA greater than 5.4cm Iliac aneurysm 3.0 cm or greater

Carotid/cerebral artery disease: Carotid stenting (CAS) and/or endarterectomy (CEA) are typically performed in a hospital but preoperative angiography may be performed in an OIS.
1. Risk of not proceeding if appropriate: stroke.
2. Procedures: angiography in preparation for CEA/CAS.
3. Indications and recommendation (applies only to preoperative angiography):

POSTPONE	PROCEED
Asymptomatic	Symptomatic (ipsilateral TIA/stroke)

Upper extremity artery disease:
1. Risk of not proceeding if appropriate: arm pain, weakness, finger wounds, finger amputation.
2. Procedures: angiography, angioplasty, stent placement.
3. Indications and recommendation:

POSTPONE	PROCEED
Asymptomatic	Acute arm/hand/finger ischemia
	Progressive tissue loss or wet gangrene

Renal artery stenosis:
1. Risk of not proceeding if appropriate: progressive renal failure, refractory hypertension, flash pulmonary edema and/or congestive heart failure due to fluid overload.
2. Procedures: angiography, angioplasty, stent placement.
3. Indications and recommendation:

POSTPONE	PROCEED
Asymptomatic	Symptomatic

Acute/Subacute/Chronic worsening mesenteric ischemia:
1. Risk of not proceeding if appropriate: weight loss, bowel perforation, and/or bowel gangrene, death.
2. Procedures: angiography, angioplasty, stent placement.
3. Indications and recommendation:

POSTPONE	PROCEED
Asymptomatic	Acute/subacute symptomatic mesenteric ischemia
	Chronic worsening symptomatic mesenteric ischemia

Superficial venous insufficiency:
1. Risk of not proceeding if appropriate: non-healing and/or worsening venous ulcerations, cellulitis, intractable pain, variceal hemorrhage/bleeding.
2. Procedures: endovenous saphenous ablation and/or suture ligation, necessary office visits and wound care/debridements.
3. Indications and recommendation:

POSTPONE	PROCEED
CEAP Class 1-5 patients (no active ulcers)	CEAP 6 (Active wounds)
Nonbleeding CVI patients	Venous ulcers – office visit and compression wrapping of leg
	Variceal bleeding or hemorrhage

Acute deep vein thrombosis (DVT):
1. Risk of not proceeding if appropriate: massive and debilitating swelling, wound formation, acute “phlegmasia” leading to limb loss, pulmonary embolism.
2. Procedures: endovenous thrombectomy/catheter extraction, catheter directed lysis, venous angioplasty and/or stent placement, intravascular ultrasound imaging.
3. Indications and recommendation:

POSTPONE	PROCEED
Asymptomatic DVT	Symptomatic iliocaval DVT
Symptomatic infrainguinal DVT except CFV as specified	Symptomatic and occlusive common femoral vein (CFV) DVT

Inferior Vena Caval (IVC) filters:
1. Risk of not proceeding if appropriate:
  1. Placements: pulmonary embolism (particularly in patients unable to be treated with anticoagulation), death.
  2. Removal: inability to remove filter in the future, IVC filter fracture, migration, IVC perforation and/or occlusion.
2. Procedures: IVC filter placement, IVC filter removal.
3. Indications and recommendation:

POSTPONE	PROCEED
	Placement if contraindication, complication, or failure of anticoagulation
	Retrieval if delay would likely prevent future retrieval (FDA recommends retrieval between 29-54 days post implant)

Vascular Access: venous ports or peripheral/central catheters (typically for immediate use of IV antibiotics or chemotherapy):
1. Risk of not proceeding if appropriate: worsening infection, cancer growth, death.
2. Procedures: angiography, central catheter placement with and without subcutaneous port.
3. Indications and recommendation:

POSTPONE	PROCEED
	Needed for immediate treatment of IV antibiotics, chemotherapy, and/or other necessary IV therapeutics

Cancer therapy:
1. Risk of not proceeding if appropriate: delay in diagnosis, delay in treatment and progression of cancer to more advanced stages, metastasis, death.
2. Procedures: biopsies, tumor chemo and/or radioembolization.
3. Indications and recommendation:

POSTPONE	PROCEED
	Suspected or proven malignancies as clinically needed

Dialysis procedures:
1. Risk of not proceeding if appropriate: electrolyte imbalance, fluid overload with pulmonary edema, uremia, cardiac arrest, uremic bleeding complications. Continuation of dialysis is required for life.
2. Procedures: angiography, angioplasty, stent placement, thrombectomy and/or lysis, tunneled or temporary central catheter placements and exchanges.
3. Indications and recommendation:

POSTPONE	PROCEED
Preop AV access creation venography and arteriography unless documented extenuating circumstances	AV fistula/graft/catheter thrombosis, malfunction, or non-functional
	Need for new access

Vascular (non-cancer) embolization:
1. Risk of not proceeding if appropriate: bleeding, pain.
2. Procedures: angiography, embolization.
3. Indications and recommendation:

POSTPONE	PROCEED
Varicoceole embolization	Uterine fibroids with ongoing bleeding requiring transfusion
Pelvic Congestion Syndrome embolization
Uterine fibroid embolization except as specified for bleeding

Compression fracture treatment:
1. Risk of not proceeding if appropriate: severe loss of conditioning and ability to perform independent activities of daily living requiring placement in nursing home or assisted living facility. Pulmonary complications (atelectasis, pneumonia, hypoxia, deep vein thrombosis/pulmonary embolism), extended use of narcotics (with associated dependency issues, constipation, respiratory compromise, development of tolerance) and difficulty avoiding social distancing (multiple physical therapy sessions-if this is even available, increased dependency on others for assistance).
2. Procedures: kyphoplasty, vertebroplasty.
3. Indications and recommendation:

POSTPONE	PROCEED
	Kyphoplasty/Vertebroplasty for acute treatment of severe acute pain or severe exacerbation of chronic underlying condition

Interventional pain management:
1. Risk of not proceeding if appropriate: extended use of narcotics (with associated dependency issues, constipation, respiratory compromise, development of tolerance) and difficulty avoiding social distancing (multiple physical therapy sessions-if this is even available, increased dependency on others for assistance.
2. Procedures: image guided epidural steroid injections, regional nerve blocks, and facet injections.
3. Procedures do not typically require utilization of PPE resources.
4. Indications and recommendation:

POSTPONE	PROCEED
	Severe acute pain or severe exacerbation of chronic underlying condition

Heart Catheterization and coronary stenting:
1. Risk of not proceeding if appropriate: myocardial infarction (MI), Congestive heart failure, death.
2. Procedures: coronary angiography, angioplasty, stent placement.
3. Indications and recommendation:

POSTPONE	PROCEED
Stable Angina	STEMI, NSTEMI (heart attacks)
Low to moderate risk stress test	Unstable angina
All other stable Valvular disease	High risk Stress test
	Moderate risk Stress test with resting SOB or chest pain
	New onset Congestive heart failure
	Critical Aortic stenosis with symptoms

Pacemaker Implantation:
1. Risk of not proceeding if appropriate: syncope/near syncope (fainting), falls, hypotension, death.
2. Procedures: pacemaker insertion, battery and/or lead placement/replacement.
3. Indications and recommendation:

POSTPONE	PROCEED
Symptomatic Bradycardia: Mild to moderate symptoms	Symptomatic Bradycardia: severe symptoms
Existing pacemaker end of life replacement: Non-Pacemaker dependent	Type 2 Mobitz heart block
	Third Degree heart block
	Existing pacemaker end of life replacement: Pacemaker dependent

Defibrillator Implant:
1. Risk of not proceeding if appropriate: sudden death, syncope/near syncope (fainting), falls, possible progressive heart failure exacerbation.
2. Procedures: defibrillator implantation, battery and/or lead placement/replacement.
3. Indications and recommendation:

POSTPONE	PROCEED
(Non BIV) ICD: if patient tolerating lifevest, may postpone until after May 8th	BIV-ICD indication: refractory symptomatic heart failure
	(Non BIV) ICD: if patient not tolerating lifevest
	Symptomatic or sustained ventricular tachycardia with EF<35%
	Existing Defibrillator end of life replacement and/or malfunctions

Situational Updates

April 7, 2020

OEIS Reaches out to Florida Governor Desantis with request for clarification regarding “elective” procedures and offers expert assistance during the Covid -19 crisis

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