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Background The COVID-19 pandemic has led to widespread postponement and cancelation of elective vascular surgeries in Switzerland. The consequences of these decisions are poorly understood. Patients and methods In this observational, retrospective, single-center cohort study, we describe the impact of COVID-19 pandemic containment strategies on patients with lower extremity peripheral arterial disease (PAD) referred during the period March 11 th -May 11 th , 2020, compared to the same time frames in 2018-2019. Patients admitted for acute limb ischemia (ALI) or chronic PAD and undergoing urgent or elective vascular surgery or primary amputation were included. Patients’ characteristics, indications for admission, and surgical features were analyzed. The occurrence of 30-day outcomes was assessed, including length of stay, rates of major adverse cardiovascular events (MACE) and major adverse limb events (MALE), and procedural and hemodynamic success. Results Overall, 166 patients were included. Fewer subjects per 10-day period were operated in 2020 compared to 2018-2019 (6.7 vs. 10.5, respectively; p < 0.001). The former had higher rates of chronic obstructive pulmonary disease (COPD) (25% vs. 11.1%; p = 0.029), and ASA score (3.13 vs. 2.90; p = 0.015). The percentage of patients with ALI in 2020 was about double that of the same period in 2018-2019 (47.5% vs. 24.6%; p = 0.006). Overall, the types of surgery were similar between 2020 and 2018-2019, while palliative care and primary amputations occurred only in 2020 (5 out 40 cases). The rate of post-operative MACE was significantly higher in 2020 (10% vs. 2.4%; p = 0.037). Conclusions During the first state of emergency for COVID-19 pandemic in 2020, less regular medical follow-up and hindered hospital access could have resulted in more acute and advanced clinical presentations of patients with PAD undergoing surgery. Guidelines are needed to provide appropriate care to this vulnerable population and avoid a large-scale disaster.

Introduction When no autologous vein is available for distal bypass in the setting of chronic limb threatening ischaemia (CLTI), new alternatives are required to solve the problems of availability, patency, and resistance to infection. An innovative technique of below the knee bypass for CLTI using a porcine self made stapled pericardial tube graft is reported. Report An 84 year old man, admitted with right CLTI with foot infection due to long occlusion of the femoropopliteal segment, required urgent revascularisation. In the absence of autologous vein and cryopreserved vessels, a 4 mm self made stapled porcine pericardial tube graft 56 cm long was created from two 14 × 8 cm patches, to perform a femorotibioperoneal trunk bypass. On day 10, bypass thrombectomy and balloon angioplasty of the distal anastomosis were needed to treat early occlusion. Oral anticoagulation was then started. Right toe pressure increased from 0 to 70 mmHg, and no infection was reported. Complete wound healing was achieved. At six months, the bypass was still patent. Discussion The use of porcine self made stapled pericardial tube grafts could offer new options for revascularisation in CLTI. Larger cohort studies with longer follow up are needed to confirm this successful preliminary experience.

Symptomatic peripheral arterial disease management involves medical treatment and interventional procedures. Intermittent claudication and critical limb threatened ischemia (CLTI) should be individually considered with specific outcomes and procedures. When intervention is required, an endovascular approach is usually the first-line option. Plain balloon angioplasty was previously used to dilate clinically significant femoropopliteal lesions with variable results. However, over recent years, the use of self-expanding nitinol stents has enabled treatment of long lesions, yielding significantly improved clinical results. Drug-eluting technology has also exhibited a capacity to limit in-stent restenosis and to drive target revascularization. Nevertheless, calcifications and elastic recoil of the arterial wall remain risk factors for early restenosis and failure. Therefore, vessel preparation using specific devices is required to modify vessel compliance and debulk obstructive calcification. In this short review, we provide an overview of the options for gaining lumen before stenting or dilation using drug-coated balloons.

The presented surgical technique offers the major advantage of avoiding organ ischemia and accelerating the surgical procedure.