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Vascular Specialist | Thursday 16 June 2022
PANDEMIC PROGNOSIS
ALI CAN OCCUR WITH OR WITHOUT ATHEROSCLEROTIC DISEASE AND PORTENDS WORSE PROGNOSIS IN COVID-19 PATIENTS By Jocelyn Hudson ACUTE LIMB ISCHEMIA (ALI) CAN OCCUR WITH or without atherosclerotic disease and portends a worse prognosis in patients with COVID-19. This risk persists after COVID-19 infection due to a lingering co-inflammatory state, and D-dimer may be a useful screening test in at-risk patients. This is according to Max V. Wohlauer, MD, assistant professor of surgery at the University of Colorado Denver in Aurora, Colorado, who yesterday outlined a study assessing revascularization outcomes of ALI in COVID-19 patients. Wohlauer delivered the presentation during a Vascular and Endovascular Society (VESS) paper session on behalf of first author Mahmood Kabeil, MD, senior author Robert F. Cuff, MD, assistant professor at Spectrum Health in Grand Rapids, Michigan, and on behalf of the Vascular Surgery COVID-19 Collaborative (VASCC). “Coagulation and inflammation are linked, and a coagulopathy has been described with SARS and other respiratory viruses,” said Wohlauer, noting an increased D-dimer and
other coagulation derangements in patients with COVID-19 infection. Giving additional context to his talk, the presenter noted that ALI is a risk factor for amputation and mortality in patients with COVID-19 infection, and that high D-dimer levels are associated with an increased risk of thrombosis in COVID-19 patients. Outlining their methods for the study in an abstract, the researchers note that VASCC formed the basis of their analysis. A registry was developed in March 2020, they write, in order to assess the impact of COVID-19 infection on vascular surgery patients and practices. At VAM, Wohlauer reported an interim data analysis of 94 patients from 18 sites across five countries with the aim of providing an insight into revascularization strategies and outcomes for COVID-19-associated ALI. The speaker noted that the 94 patients included in the interim analysis had a mean age of 64 years and that 37% were female. In this cohort, only 15% had a history of peripheral arterial disease (PAD), he added, and none had a prior hypercoagulable state. Only 2% had active cancer, and the rate of tobacco use was 21%. Wohlauer was keen to emphasize the fact that 90% of the patients in the cohort had no prior history of vascular intervention. In addition, he detailed that ALI was the initial COVID-19 presentation in 21% of the cases, with the remaining 79% experiencing ALI a median of eight days after a positive COVID-19 test. Giving further details on the patient cohort, the presenter noted that 53% were categorized as Rutherford 2b. He added that 89% of the thrombus was located in the lower extremity, 8% in the upper extremity, and 3% in the infrarenal aorta. Of the patients with lower extremity thrombus, he detailed that the majority was in the femoropopliteal region. Reporting revascularization strategies in this cohort, Wohlauer detailed that 63% of patients underwent open revascularization, 16% endovascular, and 22% had no revascu-
larization. In the patients who had no revascularization, he specified that 52% of the time it was because the limb was not salvageable. For others, it was related to the severity of COVID-19 pneumonia. In terms of other outcomes, the presenter revealed that the mean hospital stay was 14.7 days, and mean intensive care unit (ICU) stay was 5.6 days. Thirteen percent required an amputation, 5.2% had a pulmonary embolism, 5.2% had a stroke, and 6.2% had sepsis. There was a 15.5% major adverse limb event rate in this cohort. One of the key findings Wohlauer highlighted was a 31% in-hospital mortality rate. He also reported that, on the other end of the scale, 40% of patients had no major complications in hospital. Age was an independent risk factor for in-hospital mortality, he said, but was not a risk factor for major adverse limb events. Wohlauer summarized that ALI is the initial COVID-19 symptom in up to one-third of patients, and that the overwhelming majority of patients with COVID-19 ALI have no prior vascular history, and that age is an independent risk factor for mortality, but not a risk factor for major adverse limb events. D-dimer, he informed the audience, may be a useful screening test in patients at risk for COVID-19-associated ALI. He thanked all of the VASCC members who contributed data to this project, and acknowledged the VASCC Project 2 ALI Working Group. He mentioned that the study is actively recruiting patients and that the organization welcomes contributions.
“The overwhelming majority of patients with COVID-19 ALI have no prior vascular history”
INTERVIEW Vascular Surgery Interest Groups propel students’ awareness and engagement in the specialty Analysis out of Illinois records increase in vascular surgery elective choices after start of VSIG events A STUDY OF THE IMPACT OF Vascular Surgery Interest Groups (VSIGs) can have on piquing awareness and engagement of medical students in the specialty found a spike among first years taking electives in vascular surgery after a series of interest group meetings were initiated. The finding was delivered under the title “Gaining access: Events with the greatest impact on student interest in vascular surgery” during yesterday’s International Fast Talk session. Presenting author Richard Li, BS, a thirdyear medical student at Carle Illinois College of Medicine in Urbana, Illinois, and colleagues investigated the relationship between the type of event staged and the impact it had on retaining event attendees, increasing interest in vascular surgery, and enhancing knowledge and awareness of the field. Li pointed out an important backdrop to the research: These days, more than 70% of matched medical students in surgical specialties identified surgery as their top choice by the second year of medical school, he said. The Carle VSIG held four interest group
meetings throughout the school’s fall semester—one each with the group’s physician mentor, a vascular surgery resident, the program director of the Carle vascular surgery residency program, and demo deployments from industry representatives. “Before each event, students were asked to fill out a form inquiring about their interest and knowledge of the field of vascular surgery on a scale of 1–10, with 1 being the lowest interest and knowledge,” Li detailed. “After each event, students were again asked to fill out a form which included the same questions regarding their interest and knowledge of the vascular surgery field.” Li said the research team found that postevent surveys showed students as having a high interest in vascular surgery: “The average level of interest stayed consistent with minor fluctuations before and after the events. Of note, the event with the program director had the largest increase, from 5.91 to 7.53. Regarding interest in vascular surgery, each event had a high standard deviation. This could be due to students who are both changing their opinions and solidifying their thoughts about vascular surgery as a career
choice.” The students who attend the VSIG’s events tend to have an interest in vascular surgery, Li added, “and we do find that a large standard deviation for change of interest is a desirable outcome—having a student go from a two to an eight is just as important as an eight to a two.” Attendance was “very high,” he said, averaging between 20–30 students from an average class size of 50. “Why does this matter?” he pondered. Just 13% of students were interested in vascular surgery when they arrived. “Since we’ve started, over seven students have elected to do electives in vascular surgery, with five of them starting their first year of medical school—up from zero.” VSIGs “def initely” have an impact, Li said, “and I highly recommend for this to be a call to action to reach out to your VSIGs.” Li and colleagues plan to put the data
from the study to use in order to develop a series of events with “maximum impact” for increasing exposure and awareness of vascular surgery. “Event responses demonstrate that VSIGs are critical to educating medical students about vascular surgery and promoting interest in the field.” Moderator Ahmed M. Abou-Zamzam, MD, noted an element of surprise at the statistic showing they had established 13% interest in vascular surgery from “the get-go.” He further asked whether the research group had tracked elements such as food offerings. “Two of the events, we actually had no food,” Li said in response. “We still managed to get high representation.”
Richard Li
