COVID-19 case classification

We are being asked to cancel all elective and nonurgent procedures. How do we determine what to cancel?

Interventional radiology practices are being asked or required to postpone elective and nonurgent cases. A significant factor is the preservation of personal protective equipment (PPE). Determination of what qualifies as elective or nonurgent is often based on several factors including procedure, patient, co-morbidities and disease state. While there is no single way to easily categorize all procedures, each institution should decide what can be postponed on a case-by-case basis taking into account the current state of COVID-19 surges in their local area. Cases can be divided into several categories based on acuity, then triaged appropriately. Below is an example approach adapted from the American College of Surgeons Elective Surgery Acuity Scale (ESAS). It is important to recognize that the decision to cancel or perform a procedure must be made in the context of numerous local considerations, both medical and logistical. Please note that the procedure list is not comprehensive.

Interventional Radiology - Procedure Acuity Scale (IR-PAS)

Tiers/Description	Definition	Examples	Action
Tier 1	Low acuity procedure Outpatient procedure Not life-threatening illness	Non-Vascular: Thyroid Biopsy (incidental finding) Botox injections Cosmetic IR Fallopian tube recanalization Select renal ablations (e.g. T1a)* Routine tube/drain change Image guided liver biopsy for abnormal LFTs Percutaneous access for nephrolithotomy (in conjunction with Urology) LP for non-infection/neurologic causes (not including intra-thecal chemotherapy) Hysterosalpingogram Myelography Interventional Pain procedures like trigger point injections, joint and facet injections Vascular: Incidental Vascular anomaly/malformation Asymptomatic or mildly symptomatic May-Thurner syndrome IVC filter removal Varicose veins, GSV ablations EVAR - AAA < 6.5 cm Peripheral Angiogram and intervention for claudication Lower extremity venous interventions for symptomatic spider veins or superficial vein incompetence IVC Filter removal Uterine fibroid embolization Pelvic congestion embolization Prostate artery embolization Venous sampling TIPS for Ascites Central venous catheter/port removals for completion of treatment *Consider shared decision-making via virtual multi-disciplinary tumor board discussion	Postpone procedure
Tier 2	Intermediate acuity procedure Not life threatening but potential for future morbidity and mortality. Requires in hospital stay	Non-Vascular: Joint aspiration for infection Percutaneous fluid collection drainage for infection without septic shock – consider antibiotic trial first Cancer Diagnostic procedures (biopsies, aspiration) * Cancer therapy (locoregional therapy) * Tube change for malfunction or leakage Gastrostomy/GJ tube placement for nutrition Bone Augmentation/ Vertebroplasty/Kyphoplasty/ Sacroplasty Thoracentesis/Chest tube for dyspnea Therapeutic Paracentesis Vascular: Venous Thoracic outlet syndrome intervention for mild symptoms Endovascular management of asymptomatic peripheral and non-aortic intrabdominal aneurysm AAA > 6.5cm TAA > 6.5cm Fistula/Dialysis access interventions for suboptimal function Chronic mesenteric ischemia interventions Peripheral Angiogram and intervention for chronic limb threatening ischemia – rest pain or tissue loss Massive iliofemoral DVT without phlegmasia Venous intervention for ulcers in lower extremity IVC filter placement in low risk patients Central Venous Catheter or PICC line placement *Consider shared decision-making via virtual multi-disciplinary tumor board discussion	Postpone procedure if possible
Tier 3	High acuity procedure	Non-Vascular: Percutaneous fluid collection drainage for septic shock Percutaneous Nephrostomy for septic shock Percutaneous Cholecystostomy/Biliary drain for septic shock Transplant rejection solid organ biopsy Lumbar puncture for infection, acute neurologic change or intrathecal chemotherapy Vascular: Trauma interventions Pulmonary Embolism Therapy Stroke interventions Acute hemorrhage interventions/embolization Arterial lysis/thrombectomy for acute ischemia EVAR/TEVAR for ruptured or symptomatic TAAA/AAA EVAR/TEVAR for dissection with rupture or malperfusion Symptomatic Carotid artery stenosis intervention Symptomatic acute mesenteric ischemia intervention PAD for Limb ischemia: progressive tissue loss, acute limb ischemia Intravascular management of PAD leading to acute limb ischemia Endovascular management of symptomatic peripheral and non-aortic abdominal aneurysms Endovascular management of pseudoaneurysm – expanding, iatrogenic Fistula/Dialysis access interventions for thrombosis	Do not postpone

COVID-19 case classification

Updated April 8, 2020

Meetings and Education

Patient Center

Member central

Advocacy

Corporate relations

Practice resources