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Current Issue

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Vascular Surgery, Part II

Vol. 46, No. 7, 2020

  • Atherosclerosis: Epidemiology and Basic Biology
  • Carotid Occlusive Disease
  • Lower Extremity Occlusive Disease
  • Mesenteric Occlusive Disease
  • Renal Vascular Disease
Featured Commentary

The online formats of SRGS include access to What You Should Know (WYSK): commentaries on articles published recently in top medical journals. These commentaries, written by practicing surgeons and other medical experts, focus on the strengths and weaknesses of the research, as well as on the articles' contributions in advancing the field of surgery.

Below is a sample of one of the commentaries published in the current edition of WYSK.


 

MacLaren G, Fisher D, Brodie D. Treating the Most Critically Ill Patients With COVID-19: The Evolving Role of Extracorporeal Membrane Oxygenation. JAMA. 2022;327(1):31-32. doi:10.1001/jama.2021.22580

Commentary by: Joseph Cushieri, MD, FACS

As medical providers, we must continue to assess our prevention and treatment carefully as we navigate the changes in the prevention and treatment of COVID-19 and the effect of the multiple variants. One treatment option is extracorporeal membrane oxygenation (ECMO) for patients with severe COVID-19 infections. By providing pulmonary support, the patient is theoretically provided oxygenation and physiologic support that would allow therapeutics and time to fight off this devastating infection. Although used early on to treat this infection, the role of ECMO in the treatment of COVID-19 has been subjected to significant debate and controversy.

In a recent Viewpoint in JAMA, MacLaren and colleagues described the evolving role of ECMO in patients with severe respiratory failure with COVID-19.1 The authors correctly suggested that the early use of ECMO during the pandemic was based on previous experience treating patients with severe acute respiratory distress syndrome (ARDS) that were not responsive to less invasive therapies. However, no data at the time existed; thus, the most effective role of ECMO was unknown. Additionally, given the coagulation abnormalities attributed directly to COVID-19, including bleeding and thrombosis, the overall safety of ECMO was unknown. Fortunately, subsequent data has demonstrated that these risks can be minimized by careful assessment and treatment of underlying deficits in coagulation.

The authors point out that more than 10,500 patients have been treated with ECMO. But based on these and subsequently published data, an apparent increase in the mortality rate of patients treated with ECMO has been reported. In a large series published by their institution in the Lancet, mortality during the initial part of the pandemic in 2020 increased from 38% to 53% at the end of the reporting year.2 Although they agree this increase in mortality may be due to the increasing complexity of the patients treated, they question the utility of this complex therapy and the subsequent resource utilization and ethical dilemmas treating clinicians face.

This Viewpoint does bring out three important approaches that should be considered. First, given existing and accumulating data on patients that do not benefit from ECMO, consideration of ECMO use should be based on the likelihood of survival, including assessment of the degree of organ failure and associated comorbidities. Second, regional ECMO capabilities should be optimized with a coordinated response for referral as with the treatment of other conditions, including injury, stroke, and cardiovascular care. Finally, further research is needed to evaluate the role of ECMO in COVID-19 fully.

This publication highlights the importance of continued reflection on therapies for COVID-19. Although mortality may have increased for various reasons, ECMO has a role in treating patients with respiratory failure due to COVID-19. Importantly, failed therapeutic improvement, comorbidities, associated infections, and progressive organ failure that may have played a role in this reported increased mortality must be investigated and considered as to which patients may genuinely benefit from ECMO. As a result, it currently depends on individuals with the greatest experience in using ECMO to consider all these critical aspects while simultaneously considering the overall institutional resources needed and available to make the best use of this therapy for individual patients. Further research must be performed to guide the development of guidelines and strategies for ECMO use in COVID-19 to improve the use of ECMO.

References

  1. MacLaren G, Fisher D, Brodie D. Treating the Most Critically Ill Patients With COVID-19: The Evolving Role of Extracorporeal Membrane Oxygenation. JAMA. 2022;327(1):31-32. doi:10.1001/jama.2021.22580
  2. Barbaro RP, MacLaren G, Boonstra PS, et al. Extracorporeal membrane oxygenation for COVID-19: evolving outcomes from the international Extracorporeal Life Support Organization Registry. Lancet. 2021;398(10307):1230-1238. doi:10.1016/S0140-6736(21)01960-7
Recommended Reading

The SRGS Recommended Reading List is a summary of the most pertinent articles cited in each issue; the editor has carefully selected a group of current, classic, and seminal articles for further study in certain formats of SRGS. The citations below are linked to their abstracts on PubMed, and free full texts are available where indicated.

SRGS has obtained permission from journal publishers to reprint these articles. Copying and distributing these reprints is a violation of our licensing agreement with these publishers and is strictly prohibited.

Tattersall MC, Johnson HM, Mason PJ. Contemporary and Optimal Medical Management of Peripheral Arterial Disease. Surg Clin North Am. 2013;93(4):761-vii. doi:10.1016/j.suc.2013.04.009

Tattersall and coauthors reviewed the evidence supporting the use of several medical interventions to control symptoms and progression of peripheral arterial disease. Smoking cessation, diabetes control, and weight loss were some of the interventions discussed.

Beckman JA, Schneider PA, Conte MS. Advances in Revascularization for Peripheral Artery Disease: Revascularization in PAD. Circ Res. 2021;128(12):1885-1912. doi:10.1161/CIRCRESAHA.121.318261

This article provided insightful information on the value of a multidisciplinary approach to the management of patients with peripheral arterial disease. Therapeutic strategies are based on precise diagnosis, including identification and localization of atherosclerotic lesions and quantifying the severity of disease. Guidance for the use of open or endovascular approaches was provided as well.

Bala M, Catena F, Kashuk J, et al. Acute mesenteric ischemia: updated guidelines of the World Society of Emergency Surgery. World J Emerg Surg. 2022;17(1):54. Published 2022 Oct 19. doi:10.1186/s13017-022-00443-x

Using a careful evaluation of available evidence and expert consensus, this set of guidelines provides useful information for clinicians caring for patients with mesenteric ischemia. The guidelines stress the importance of reducing diagnostic delay, adequate resuscitation, prompt exploratory surgery with resection of infarcted bowel, and revascularization for acute mesenteric ischemia. Relevant anatomy and surgical approaches are clearly described.

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