key: cord-0938999-ua7kuvio
authors: Lee, Kyungmouk Steve; Talenfeld, Adam D.; Browne, William F.; Holzwanger, Daniel J.; Harnain, Christopher; Kesselman, Andrew; Pua, Bradley B.
title: Role of interventional radiology in the treatment of COVID-19 patients: early experience from an epicenter
date: 2020-11-05
journal: Clin Imaging
DOI: 10.1016/j.clinimag.2020.10.048
sha: 3c5567d514b27d4986497ad39f65d558837c3b1e
doc_id: 938999
cord_uid: ua7kuvio

OBJECTIVE: To highlight the role of interventional radiology (IR) in the treatment of patients hospitalized with coronavirus disease 2019 (COVID-19). METHODS: Retrospective review of hospitalized patients who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and had one or more IR procedures at a tertiary referral hospital in New York City during a 6-week period in April and May of 2020. RESULTS: Of the 724 patients admitted with COVID-19, 92 (12.7%) underwent 124 interventional radiology procedures (79.8% in IR suite, 20.2% at bedside). The median age of IR patients was 63 years (range 24–86 years); 39.1% were female; 35.9% in the intensive care unit. The most commonly performed IR procedures were central venous catheter placement (31.5%), inferior vena cava filter placement (9.7%), angiography/embolization (4.8%), gastrostomy tube placement (9.7%), image-guided biopsy (10.5%), abscess drainage (9.7%), and cholecystostomy tube placement (6.5%). Thoracentesis/chest tube placement and nephrostomy tube placement were also performed as well as catheter-directed thrombolysis of massive pulmonary embolism and thrombectomy of deep vein thrombosis. General anesthesia (10.5%), monitored anesthesia care (18.5%), moderate sedation (29.8%), or local anesthetic (41.1%) was utilized. There were 3 (2.4%) minor complications (SIR adverse event class B), 1 (0.8%) major complication (class C), and no procedure-related death. With a median follow-up of 4.3 months, 1.1% of patients remain hospitalized, 16.3% died, and 82.6% were discharged. CONCLUSION: Interventional radiology participated in the care of hospitalized COVID-19 patients by performing a wide variety of necessary procedures.

(range 24-86 years); 39.1% were female; 35.9% in the intensive care unit. The most commonly performed IR procedures were central venous catheter placement (31.5%), inferior vena cava filter placement (9.7%), angiography/embolization (4.8%), gastrostomy tube placement (9.7%), image-guided biopsy (10.5%), abscess drainage (9.7%), and cholecystostomy tube placement (6.5%). Thoracentesis/chest tube placement and nephrostomy tube placement were also performed as well as catheter-directed thrombolysis of massive pulmonary embolism and thrombectomy of deep vein thrombosis. General anesthesia (10.5%), monitored anesthesia care (18.5%), moderate sedation (29.8%), or local anesthetic (41.1%) was utilized. There were 3 (2.4%) minor complications (SIR adverse event class B), 1 (0.8%) major complication (class C), and no procedure-related death. With a median follow-up of 4.3 months,

Coronavirus disease 2019 (COVID-19) is a global pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [1] . SARS-CoV-2 enters human cells via the angiotensin-converting enzyme 2 (ACE2) receptors that are found in the lung, heart, kidney, intestine and vascular endothelium [2] . In severe COVID-19, patients may develop respiratory distress, renal failure, cardiac injury as well as venous and arterial thromboembolism [3, 4] . Working alongside other medical and surgical specialties, interventional radiology (IR) can play a role in the management of coronavirusrelated complications [5] [6] [7] . For COVID-19 patients with renal failure, IR physicians may leverage their expertise in image-guided techniques to place hemodialysis catheters even in patients with challenging anatomy due to venous thromboembolism (VTE) [8] . For select patients with VTE, interventional radiologists may place inferior vena cava (IVC) filters as well as perform catheter-directed thrombolysis / thrombectomy for massive or submassive pulmonary embolism and proximal deep vein thrombosis [9- J o u r n a l P r e -p r o o f 11] . Furthermore, in COVID-19 patients who develop life-threatening bleeding complications while on   anticoagulant therapy for VTE, interventional radiologists may perform embolization procedures to treat   arterial bleeding. In critically ill coronavirus patients who develop acute cholecystitis and abscesses, IR   physicians may place percutaneous cholecystostomy tubes and drainage catheters. For COVID-19 patients who may be suffering from severe dysphagia and malnutrition, percutaneous gastrostomy feeding tubes may be placed in IR with theoretically less aerosolization risk than endoscopic methods.

At the peak of the coronavirus pandemic, limitations in operating room facilities and ventilators at our hospital shifted the paradigm of care to minimally invasive therapies requiring minimal sedation.

As physicians specializing in minimally invasive and image-guided techniques, interventional radiologists are ideally suited to adapting to the COVID-19 environment and delivering safe and effective care to patients. In this study, we describe the utilization of interventional radiology services in coronavirus patients at a tertiary care center in New York City, the epicenter of the COVID-19 pandemic, in April and May of 2020.

In this institutional review board-approved retrospective study, we reviewed patients admitted with COVID-19 who underwent one or more interventional radiology procedures during a 6-week period between April 3, 2020 (first date of increased IR utilization in coronavirus patients) and May 15, 2020 at a tertiary referral hospital in New York City. Increased IR utilization was defined as more than one IR procedure on a COVID-19 patient per day. Clinical outcomes were observed until September 4, 2020, the final date of follow-up. COVID-19 status was confirmed prior to the IR procedure by a reversetranscriptase-polymerase-chain-reaction (RT-PCR) assay detecting the presence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) RNA in a nasopharyngeal swab specimen. IR procedures were performed by or under the supervision of a board-certified interventional radiologist, and appropriate personal protective equipment was used as per institutional and IR division guidelines. Patient J o u r n a l P r e -p r o o f demographic information and clinical data were collected from the electronic medical record system, including: type of IR procedure; location of the IR procedure; type of sedation utilized during IR procedure; complications of the IR procedure; status and length of the hospital stay at the time of lastfollow-up. Adverse events were categorized based on the Society of Interventional Radiology (SIR) adverse events classification system.

Among the 724 patients hospitalized with confirmed COVID-19, there were 92 (12.7%) patients who underwent a total of 124 interventional radiology procedures. Of these 92 patients, the median age 

Interventional radiology procedures have contributed to the care of COVID-19 patients worldwide. Reports from Europe, Asia, and North America outline the safety precautions utilized during the COVID-19 pandemic in performing IR procedures [7, [12] [13] [14] . In the largest study of IR procedures during the COVID-19 pandemic, 550 patients underwent 671 procedures at a tertiary care hospital in Italy [12] ; this study found that there were no incidents of cross-infection and no reports of COVID-19 infection of healthcare worked in the IR service. However, in this Italian study, only nine (1.34%) patients were classified as "suspected" and only one patient (0.15%) was confirmed positive for SARS-CoV-2. In contrast, all patients in our study had confirmed SARS-CoV-2 by RT-PCR testing. In treating COVID-19 patients, infectious prevention strategies were instituted including altering the workflow to minimize contact time, using adequate PPE, following proper wait times as well as followinf strict cleaning protocols between cases [15] . Bedside procedures were utilized as much as possible to minimize transport of patients and to conserve PPE. Compared to surgeries in the operating room, interventional radiology procedures may potentially require less PPE and less support staff [16, 17] .

COVID-19 may target the pulmonary, cardiovascular, renal, hepatobiliary, intestinal and neurologic systems [18] [19] [20] [21] [22] . The resultant multi-organ dysfunction associated with COVID-19 necessitates a multi-disciplinary approach to treatment, with interventional radiology contributing to the care of many patients (See Table 1 ). In severe COVID-19, venous thromboembolism appears to be common, with early studies showing VTE in 36% of patients and acute pulmonary embolism (PE) in 30% of patients who underwent imaging tests [23] [24] [25] . However, the management of VTE is challenging due to the complex relationship between coagulation abnormalities and antithrombotic therapy in COVID-19 patients [9, 10] . In particular, the role of inferior vena cava (IVC) filters in coronavirus patients is not entirely clear. At our institution, indications for filter placement in COVID-19 patients were DVT/PE with contraindication to anticoagulation due to bleeding, new DVT/PE while on anticoagulation, and acute iliofemoral DVT extending into the IVC. For select patients with massive or submassive pulmonary embolism, escalation of therapy to catheter-directed thrombolysis may have less bleeding risk than J o u r n a l P r e -p r o o f systemic lytic therapy [11] . In our early COVID-19 experience, one patient was treated with catheterdirected thrombolysis for massive pulmonary embolism; this coronavirus patient was successfully discharged home 6 days after the IR procedure. Thrombectomy of extensive proximal deep vein thrombosis was also performed in one COVID-19 patient at our institution; this patient demonstrated symptomatic improvement post-procedurally and was discharged 3 weeks afterwards. Renal complications are also common in COVID-19 with acute kidney injury occurring in 36.6% of hospitalized patients, among which 14.3% required renal replacement therapy [8] . Patients needing hemodialysis will need placement of large bore central venous catheters, which may be provided by interventional radiologists. IR physicians can also place peritoneal dialysis catheters as well as provide maintenance of arteriovenous access site (fistula and graft management). J o u r n a l P r e -p r o o f 

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This retrospective study was approved by the Institutional Review Board (IRB). For this type of study formal consent is not required.

This study has obtained IRB approval from the Weill Cornell Medicine IRB committee and the need for informed consent was waived.

For this type of study consent for publication is not required.