COVID-19 Impact on Vascular Surgery Practice: Experience From an Italian University Regional Hub Center for Vascular Pathology

Work Environment Differences Between Outpatient and Inpatient Surgery: A Pilot Study on the Vascular Surgeons' Perceptions

BACKGROUND

In France, outpatient endovascular surgical procedures have been slowly implemented in hospitals since 2015. Their development has been heterogeneous across France and is not yet the standard of care despite their benefits concerning patients' outcomes and healthcare professionals' satisfaction. However, since the COVID-19 pandemic, the demand for patient beds has been increasing, while human resources have been decreasing. This encouraged the surgery service reorganization and accelerated the shift from inpatient to outpatient surgery. Consequently, services had to adapt rapidly and this may have caused some strain on the hospital medical workforce. The objectives of this pilot study were to document and analyze the nursing staff (nurses and certified assistant nurses) well-being and workload as perceived by the vascular surgeons working with them. It also wanted to assess the link between the nursing staff's psychosocial stress and the surgeons' concentration and serenity in their workplace, based on the assumption that the well-being of both parties is inextricably linked.

METHODS

An observational study was conducted using an online questionnaire distributed to the senior members of the French society of vascular and endovascular surgery (n = 490) between October 10 and October 18, 2022.

RESULTS

In total, 125 surgeons completed the questionnaire (25% response rate). The main finding was that according to 68% of vascular surgeons, the nursing staff's psychosocial stress significantly impaired their serenity and concentration at work and this frequently affected the surgical procedure safety. The main sources of psychosocial stress were the high work pace (64%), demand for flexibility (56%), lack of anticipation of schedule changes (82%), and difficulties encountered in relaying these concerns to hospital managers (44.6%).

CONCLUSIONS

This study demonstrated that concomitantly with the forced acceleration of outpatient activity implementation, the vascular surgeons' perceptions of their working environment are deteriorating, especially in conventional (inpatient) surgery wards where the workload is increasing and patients have more comorbidities. The worsened psychosocial stress of surgeons and staff affects the care provided.

The impact of the first and the second wave of the COVID-19 pandemic on vascular surgery practice in the leading regional center: a comparative, retrospective study

BACKGROUND

We conducted an analysis of the vascular surgery regional center reorganization in response to the first and the second wave of the coronavirus disease-2019 (COVID-19) pandemic to see what lessons we learned from the first wave.

METHODS

The study included a total of 632 patients admitted to the vascular surgery department in three periods: March-May 2020, October-December 2020, and October-December 2019 as a control period.

RESULTS

In the pandemic periods the number of admitted patients decreased in relation to the control period. There was a reduction in performed procedures. We observed an increase in the ratio of less invasive procedures. There was a significant decline in hospitalization time in comparison to the control period.

CONCLUSIONS

The reduction of scheduled admissions and procedures affected vascular centers all over the world. Minimally invasive procedures were more willingly performed to shorten the hospitalization time and reduce the patient's exposure to hospital infection. It allowed us to treat more patients during the second wave. Nevertheless, an increased number of vascular patients should be expected in the future, which will result from the failure to perform elective procedures during the pandemic.

The Management of Patients with Popliteal Artery Aneurysms Presenting with Acute Limb Ischemia

INTRODUCTION

Endovascular popliteal artery aneurysm (PAA) repair has acceptable outcomes compared to open repair for elective therapy. Endovascular repair for urgent PAA causing acute limb ischemia (ALI) has not been well studied. This project compares outcomes of urgent endovascular and open repair of PAA with ALI.

METHODS

The Vascular Quality Initiative database for peripheral vascular interventions and infrainguinal bypass were reviewed for PAA with ALI from 2010 to 2021. Only patients entered as having symptoms of ALI in the PVI module and ALI as indication in the infrainguinal bypass module were included. In addition, patients undergoing elective treatment were excluded and the sample analyzed was restricted to patients undergoing urgent and emergent open and endovascular repair. Patient demographics and comorbidities as well as procedural details were compared between the two groups. Perioperative complications up to 30 days were compared as well as long-term outcomes including major amputation and mortality at one year.

RESULTS

Urgent PAA repair for ALI constituted 10.5% (N=571) of all PAA. Most urgent repairs were open (80.6%, n=460) with 19.4% (n=111) endovascular. The proportion of endovascular repair significantly increased from 16.7% in 2010 to 85.7% in 2021. Patients undergoing endovascular repair were older (71.2 ± 12.5 vs 68.0 ± 11.8, p=0.011) than patients undergoing open repair. They were also more likely to have coronary artery disease (32.4% vs 21.7%, p=0.006). Open PAA repair was associated with more bleeding complications (20.8% vs 2.7%, p<0.001), longer post-op length of stay (8.1 ± 9.3 days vs 4.9 ± 5.6 days, p<0.001), and less likelihood of discharge to home (64.9% vs 70.3%, p=0.051). Perioperative major amputation rate was 7.5% with no difference between the two treatment strategies up to one year. However, patients receiving endovascular repair had higher inpatient (1.1% vs 0%, p<0.001), 30-day (6.3% vs 0.4%, p<0.001), and 1-year (16.5% vs 8.4%. P=0.02) mortality. Multivariable regression analysis suggested that endovascular repair was possibly associated with increased 30-day mortality, but not 1-year mortality.

CONCLUSION

Endovascular PAA has exponentially increased from 2010 to 2021. Endovascular repair is associated with decreased complications and hospital length of stay. The increased perioperative mortality seen in this group is likely due to selection bias.

Symptomatic Popliteal Artery Aneurysms in Recently SARS-CoV-2-Infected Patients: The Microangiopathic Thrombosis That Undermines Treatment

BACKGROUND

Arterial and venous thrombosis are complications in SARS-CoV-2-infected patients. The microangiopathic thrombosis in affected patients can compromise results in urgent limb revascularizations. Aim of our study is to report on the incidence of symptoms development in patients affected by popliteal artery aneurysm (PAA) and to analyze the effect of COVID-19 infection on outcomes.

METHODS

Data on patients surgically treated for PAA from the massive widespread of COVID-19 vaccine (March 2021) to March 2022 were prospectively collected. Factors considered for analysis were: presence of symptoms, aneurysm diameter and length, time from symptom onset and hospital referral, ongoing or recently COVID-19 infection. Outcomes measures were: death, amputation, and neurological deficit.

RESULTS

Between March 2021 and March 2022, 35 patients were surgically treated for PAA. Among them 15 referred to our hospital for symptomatic PAA and were urgently treated. Urgent treatments included both endovascular procedures and open surgeries. Nine out of 15 symptomatic patients had an ongoing or recently recovered COVID-19 infection. COVID-19 infection was strongly associated to symptoms development in patients affected by PAA and to surgical failure in those patients (OR 40, 95% CI 2.01-794.31, p = 0.005).

CONCLUSION

In our series, presence of COVID-19 infection was strongly associated to ischemic symptoms onset and to complications after urgent treatment in symptomatic patients.

Clinical and economic impact of COVID in Vascular Surgery at a Tertiary University 'Hub' Hospital of Italy

Background

Since the first cases of a novel respiratory disease were reported in December 2019, coronavirus disease (COVID-19) Emergency State (Cov-ES) caused a worldwide outbreak requiring a complete reorganization of the healthcare system and new management of its personnel; aim of this study was to analyze the clinical and financial impact of Cov-ES in the Department of Vascular Surgery at a Tertiary University “Hub” Hospital in northeast Italy.

Methods

Differences in clinical practice according to Diagnostic Related Group (DRG) and International Statistical Classification of Diseases (ICD) and Related Health Problems and the financial impact of Cov-ES were considered. Vascular procedures performed between March 2019 and December 2019 (Prepandemic) were compared to those performed in the period March–December 2020 (Pandemic). Prepandemic and pandemic reimbursements of all vascular activities and the top 3 vascular diagnoses were evaluated.

Results

Prepandemic versus pandemic era documented a decrease of vascular consultations performed (2,882 vs. 2,270, −21.2%). The number of total vascular procedures decreased from 997 to 797 (−20.1%) with a higher reduction observed in outpatient surgical activities (247 to 136, −45.0%, P = 0.0005) rather than inpatient surgical activities (750 vs. 661, 11.9%, P = 0.02). Length of hospital stay (LOS) increased from 3.3 ± 2.7 days in prepandemic to 5.3 ± 3.9 in the pandemic era (P = 0.004). Among patients with limb-threatening ischemia, the rate of major limb amputation was higher in the pandemic (3.3% vs. 5.4%, respectively, P = 0.02), and a higher rate of elective hospitalization procedures was performed as urgent/emerging setting after clinical deterioration (2.8 % vs. 6.4%, P = 0.0002). According to DRG classification, an increase of “complicated” limb-threatening ischemia (DRG 554) and aortic aneurysm (DRG 110) was observed prepandemic to pandemic (+84.2% and +25.0%, respectively). Total reimbursement for vascular activities between pandemic versus prepandemic was 4,646,108€ vs. 5,054,398€, respectively (−8.0%). Management of “complicated” limb-threatening ischemia (DRG 554) and aortic aneurysm (DRG 110) required a higher clinical and financial support that was translated into higher economic reimbursement during the pandemic (273,035€ vs. 150,005€, +82.0% and 749,250€ vs. 603,680€, +24.1%, respectively).

Conclusions

During the pandemic, the main resources were employed for the treatment of limb-threatening ischemia, aortic aneurysm, and carotid stenosis. Inpatient activities documented an increase in major limb amputation and LOS. An increased reimbursement for each vascular procedure and for all “complicated” diagnoses revealed that the more serious and resource-demanding pathology occurred in this period.

Editor's Choice - Update of the European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia in Light of the COVID-19 Pandemic, Based on a Scoping Review of the Literature

OBJECTIVE

To perform a scoping review of how patients with COVID-19 are affected by acute limb ischaemia (ALI) and evaluate the recommendations of the 2020 ESVS ALI Guidelines for these patients.

METHODS

Research questions were defined, and a systematic literature search was performed following the PRISMA guidelines. Abstracts and unpublished literature were not included. The definition of ALI in this review is in accordance with the ESVS guidelines.

RESULTS

Most identified papers were case reports or case series, although population based data and data from randomised controlled trials were also identified. In total, 114 unique and relevant papers were retrieved. Data were conflicting concerning whether the incidence of ALI increased, or remained unchanged, during the pandemic. Case reports and series reported ALI in patients who were younger and healthier than usual, with a greater proportion affecting the upper limb. Whether or not this is coincidental remains uncertain. The proportion of men/women affected seems unchanged. Most reported cases were in hospitalised patients with severe COVID-19. Patients with ALI as their first manifestation of COVID-19 were reported. Patients with ALI have a worse outcome if they have a simultaneous COVID-19 infection. High levels of D-dimer may predict the occurrence of arterial thromboembolic events in patients with COVID-19. Heparin resistance was observed. Anticoagulation should be given to hospitalised COVID-19 patients in prophylactic dosage. Most of the treatment recommendations from the ESVS Guidelines remained relevant, but the following were modified regarding patients with COVID-19 and ALI: 1) CTA imaging before revascularisation should include the entire aorta and iliac arteries; 2) there should be a high index of suspicion, early testing for COVID-19 infection and protective measures are advised; and 3) there should be preferential use of local or locoregional anaesthesia during revascularisation.

CONCLUSION

Although the epidemiology of ALI has changed during the pandemic, the recommendations of the ESVS ALI Guidelines remain valid. The above mentioned minor modifications should be considered in patients with COVID-19 and ALI.

COVID-19 lockdown attack on headache emergency admissions: a multidisciplinary retrospective study

Background

During the first COVID-19 lockdown in Italy, it was observed a reduction in emergency department (ED) attendances due to non-SARS-COV-2-related acute/chronic conditions.

Objective

To analyze the impact of the COVID-19 lockdown on patients reporting headache as the principal presenting symptom on admission to the ED of the tertiary care University Hospital of Trieste over the relevant period.

Methods

We retrospectively evaluated the frequency, features, and management of ED attendances for headache during the COVID-19 lockdown from 8 March to 31 May 2020, comparing it with the pre-lockdown period (January–February 2020) and the first 5 months of 2019.

Results

A reduction in ED total attendances was observed in the first 5 months of 2020 compared to the same period in 2019 (21.574 and 30.364, respectively; − 29%), in particular with respect to headache-related attendances (174 and 339 respectively; − 49%). During the COVID-19 lockdown, it was recorded a minor reduction in the ED access rate of female patients (p = 0.03), while no significant variation was detected in repeaters’ prevalence, diagnostic assessment, and acute treatment. The ratio of not otherwise specified, secondary, and primary headaches (48.4%, 30.6%, and 21.0% respectively) remained unchanged during the COVID-19 lockdown, in comparison to the control periods.

Conclusion

The COVID-19 pandemic impacted the number of ED attendances for headache but not their management and setting. Despite a reduction of accesses for headache due to the pandemic emergency, the distribution of headache subtypes and the rate of repeaters did not change.

A scoping review on the changes in vascular surgical practice during the early phases of the COVID-19 pandemic

The coronavirus disease 2019 (COVID-19) pandemic has had a profound effect on the delivery of vascular surgery to patients around the world. In order to conserve resources and reduce the risk of COVID-19 infection, many institutions have postponed or cancelled surgical procedures. In this scoping review, we aim to review current literature and recapitulate the significant changes in elective and emergency vascular surgery during the COVID-19 pandemic. We conducted this scoping review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews. We included all articles that had reported the effects of the COVID-19 pandemic on elective or emergency vascular surgery. A total of 28 articles were included in this scoping review. We identified eight distinct themes that were relevant to our study topic. We report global, regional, and local data on vascular surgical cases. We also discuss the adoption of vascular surgery triage systems, emergence of global collaborative vascular surgery research groups, increased use of endovascular techniques and locoregional anesthesia, delayed presentation of vascular surgery conditions, and poorer outcomes of patients with chronic limb threatening ischemia. This scoping review provides a snapshot of the impact of the COVID-19 pandemic on elective and emergency vascular surgery.