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.