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OEIS Procedural Conduct Recommendations during the COVID-19 Crisis of 2020April 6, 2020Peripheral Arterial Disease (PAD):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). Procedures: angiography, angioplasty, atherectomy, stent placement.Indications and recommendations:POSTPONEPROCEEDRutherford 1-3 (claudication)Rutherford 4 (ischemic rest pain): moderate to severeRutherford 4 (ischemic rest pain): mildRutherford 5 (progressive ischemic wounds)Rutherford 6 (wet gangrene)Distal embolization: with wounds or tissue lossVascular Bypass and/or stent(s) with severe stenosis felt to be at risk of thrombosisAbdominal aortic aneurysm (AAA) repair is performed in the hospital but is often preceded by planning or preparatory procedures such as embolization:Risk of not proceeding if appropriate: aneurysm rupture and death.Procedures: angiography, angioplasty, atherectomy, stent placement.Indications and recommendation (these recommendations concern the outpatient planning or preparatory procedures only):POSTPONEPROCEEDAsymptomatic AAA less than 5.4 cmAsymptomatic AAA greater than 5.4cmIliac aneurysm 3.0 cm or greaterCarotid/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.Risk of not proceeding if appropriate: stroke.Procedures: angiography in preparation for CEA/CAS.Indications and recommendation (applies only to preoperative angiography):POSTPONEPROCEEDAsymptomaticSymptomatic (ipsilateral TIA/stroke) Upper extremity artery disease:Risk of not proceeding if appropriate: arm pain,weakness, finger wounds, finger amputation.Procedures: angiography, angioplasty, stent placement.Indications and recommendation:POSTPONEPROCEEDAsymptomaticAcute arm/hand/finger ischemiaProgressive tissue loss or wet gangrene Renal artery stenosis:Risk of not proceeding if appropriate: progressive renal failure, refractory hypertension, flash pulmonary edema and/or congestive heart failure due to fluid overload. Procedures: angiography, angioplasty, stent placement.Indications and recommendation:POSTPONEPROCEEDAsymptomaticSymptomaticAcute/Subacute/Chronic worsening mesenteric ischemia: Risk of not proceeding if appropriate: weight loss, bowel perforation, and/or bowel gangrene, death.Procedures: angiography, angioplasty, stent placement.Indications and recommendation:POSTPONEPROCEEDAsymptomaticAcute/subacute symptomatic mesenteric ischemiaChronic worsening symptomatic mesenteric ischemiaSuperficial venous insufficiency:Risk of not proceeding if appropriate: non-healing and/or worsening venous ulcerations, cellulitis, intractable pain, variceal hemorrhage/bleeding.Procedures: endovenous saphenous ablation and/or suture ligation, necessary office visits and wound care/debridements.Indications and recommendation:POSTPONEPROCEEDCEAP Class 1-5 patients (no active ulcers)Nonbleeding CVI patientsCEAP 6 (Active woundsVenous ulcers- office visit and compression wrapping of legVariceal bleeding or hemorrhageAcute deep vein thrombosis (DVT):Risk of not proceeding if appropriate: massive and debilitating swelling, wound formation, acute “phlegmasia” leading to limb loss, pulmonary embolism.Procedures: endovenous thrombectomy/catheter extraction, catheter directed lysis, venous angioplasty and/or stent placement, intravascular ultrasound imaging.Indications and recommendation:POSTPONEPROCEEDAsymptomatic DVTSymptomatic infrainguinal DVT except CFV as specifiedSymptomatic iliocaval DVTSymptomatic and occlusive common femoral vein (CFV) DVTInferior Vena Caval (IVC) filters: Risk of not proceeding if appropriate:Placements: pulmonary embolism (particularly in patients unable to be treated with anticoagulation), death.Removal: inability to remove filter in the future, IVC filter fracture, migration, IVC perforation and/or occlusion.Procedures: IVC filter placement, IVC filter removal.Indications and recommendation:POSTPONEPROCEEDPlacement if contraindication, complication, or failure of anticoagulationRetrieval 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): Risk of not proceeding if appropriate: worsening infection, cancer growth, death.Procedures: angiography, central catheter placement with and without subcutaneous port.Indications and recommendation:POSTPONEPROCEEDNeeded for immediate treatment of IV antibiotics, chemotherapy, and/or other necessary IV therapeuticsCancer therapy: Risk of not proceeding if appropriate: delay in diagnosis, delay in treatment and progression of cancer to more advanced stages, metastasis, death.Procedures: biopsies, tumor chemo and/or radioembolization.Indications and recommendation:POSTPONEPROCEEDSuspected or proven malignancies as clinically neededDialysis procedures: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.Procedures: angiography, angioplasty, stent placement, thrombectomy and/or lysis, tunneled or temporary central catheter placements and exchanges.Indications and recommendation:POSTPONEPROCEEDPreop AV access creation venography and arteriography unless documented extenuating circumstancesAV fistula/graft/catheter thrombosis, malfunction, or non-functionalNeed for new access Vascular (non-cancer) embolization: Risk of not proceeding if appropriate: bleeding, pain.Procedures: angiography, embolization.Indications and recommendation:POSTPONEPROCEEDVaricoceole embolizationPelvic Congestion Syndrome embolizationUterine fibroid embolization except as specified for bleedingUterine fibroids with ongoing bleeding requiring transfusionCompression fracture treatment:?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).Procedures:?kyphoplasty, vertebroplasty.c)?Indications and recommendation:POSTPONEPROCEEDKyphoplasty/Vertebroplasty for acute treatment of severe acute pain or severe exacerbation of chronic underlying conditionInterventional pain?management: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.Procedures:?image guided epidural steroid injections, regional nerve?blocks, and facet injections.Procedures do not typically require utilization of PPE resources.Indications and recommendation:POSTPONEPROCEED?Severe acute pain or severe exacerbation of chronic underlying condition?Heart Catheterization and coronary stenting:Risk of not proceeding if appropriate: myocardial infarction (MI), Congestive heart failure, death.Procedures: coronary angiography, angioplasty, stent placement.Indications and recommendation:POSTPONEPROCEEDStable AnginaLow to moderate risk stress testAll other stable Valvular diseaseSTEMI, NSTEMI (heart attacks)Unstable anginaHigh risk Stress testModerate risk Stress test with resting SOB or chest painNew onset Congestive heart failureCritical Aortic stenosis with symptomsPacemaker Implantation: Risk of not proceeding if appropriate: syncope/near syncope (fainting), falls, hypotension, death.Procedures: pacemaker insertion, battery and/or lead placement/replacement.Indications and recommendation:POSTPONEPROCEEDSymptomatic Bradycardia: Mild to moderate symptomsExisting pacemaker end of life replacement: Non-Pacemaker dependentSymptomatic Bradycardia: severe symptoms Type 2 Mobitz heart blockThird Degree heart blockExisting pacemaker end of life replacement: Pacemaker dependentDefibrillator Implant: Risk of not proceeding if appropriate: sudden death, syncope/near syncope (fainting), falls, possible progressive heart failure exacerbation.Procedures: defibrillator implantation, battery and/or lead placement/replacement.Indications and recommendation:POSTPONEPROCEED(Non BIV) ICD: if patient tolerating lifevest, may postpone until after May 8thBIV-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 ................
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