VASCULAR SURGERY
For what concerns the vascular surgery side, we did not observe a
complete flattening of activity at the spokes as expected. To the 34
confirmed surgical interventions performed during the study period at
spoke centers, we should probably add the ones that were not disclosed
by other affiliated institutions. This scenario could be explained by
some reasons, including the one that, historically, vascular pathology
is more widespread among the population and associated with a higher
incidence of urgency and emergency than cardiac surgery one. As a
consequence, some necessary interventions were performed at the spoke
centers; nonetheless, the mean number of surgical procedures by spokes
was low (7patients/center). Some patients, especially those affected by
acute and critical limb ischemia (a total of 30) with severe pneumonia
COVID related, could not be transferred from spoke centers due to their
severe general condition. In this context, the presence at the spokes of
vascular surgeons available for other urgent/emergent networks such as
stroke and trauma led to easier management of non-transportable vascular
emergencies. Another non-negligible aspect was represented by the
critical organization of transport to the HUB center due to the reduced
availability of ambulances during the peak of the pandemic; this is
highlighted by observing a protracted time of transfer (median 90
minutes, with a median distance of 55 km). In general, although
available data are partial, we had seen a reduction of elective surgical
activity compared to the same period of 2019. The main finding after the
first 30-days experience of our Institution as a Hub for vascular
disease is a significant increase of incidence of urgent interventions
especially of acute limb ischemia (ALI) compared to the pre-COVID era.
The boost of emergency department access for ALI during the pandemic
could be interpreted by a hypercoagulability state of patients affected
by this viral infection. Recently published studies showed an abnormal
increase of coagulation and cardiac biomarkers in COVID-19 patients,
which reflects an inflammatory status characterized by coagulation
activation and endothelium dysfunction 11Tang N, Li D, Wang X,
Sun Z. Abnormal coagulation parameters are associated with poor
prognosis in patients with novel coronavirus pneumonia. J Thromb
Haemost 2020 doi:10.1111/jth.14768, 22K.J.
Clerkin, J.A. Fried, J. Raikhelkar, G. Sayer, J.M. Griffin, A.
Masoumi, et al., Coronavirus disease 2019 (COVID-19) and
cardiovascular disease, Circulation. (2020),
doi:10.1161/CIRCULATIONAHA.120.046941, 33F.
Zhou, T. Yu, R. Du, G. Fan, Y. Liu, Z. Liu, et al., Clinical course
and risk factors for mortality of adult inpatients with COVID-19 in
Wuhan, China: a retrospective cohort study, Lancet. 395 (10229) (2020)
1054–1062. This hypercoagulability state leads to a recurrence of
arterial and deep venous thrombosis refractory to anticoagulant
prophylaxis 44Lodigiani C, Iapichino G, Carenzo L, Cecconi
M, Ferrazzi P, et al. Humanitas COVID-19 Task Force Venous and
arterial thromboembolic complications in COVID-19 patients admitted to
an academic hospital in Milan, Italy. Thromb Res. 2020 Apr
23;191:9-14. doi: 10.1016/j.thromres.2020.04.024 and, in our series,
to surgical intervention. Correlation between coagulation disorders and
failure of peripheral arterial revascularization is well known55Torrealba JI,
Osman M, Kelso R. Hypercoagulability predicts worse outcomes in young
patients undergoing lower extremity revascularization. J Vasc Surg
2019; 70: 175-180 doi: 10.1016/j.jvs.2018.09.062 and could explain
our disappointing rate of success (23% of all interventions of which
77,8 in COVID + patients). In our experience, we had good results in
term of revascularization by adopting a more aggressive therapeutic
attitude with intraoperative thrombolysis and postoperative infusion of
heparin as proposed in our recently published protocol66Bellosta
R, Luzzani L, Natalini G, Pegorer MA, Attisani L, Cossu LG, et al. -
Acute limb ischemia in patients with COVID-19 pneumonia, Journal of
Vascular Surgery (2020),
doi: https://doi.org/10.1016/j.jvs.2020.04.483. Lastly, overall
in-hospital mortality was high, especially for patients with concomitant
COVID 19 infection; however, the mortality rate of non-infected patients
was comparable to the non-COVID era.