The effects of COVID-19 pandemic on patients with lower extremity peripheral arterial disease: A near miss disaster

Abstract

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.

Temporal Trends in Patients with Peripheral Artery Disease Influenced by COVID-19 Pandemic

“…In line with our findings, a large epidemiological study investigating health care data of England showed that absolute numbers of amputations and revascularizations of patients with diabetes mellitus were substantially reduced during the pandemic versus the pre-pandemic phase [ 35 ]. Other studies revealed that hospitalized PAD patients during the pandemic showed increased severity of PAD and more acute complications [ 14 , 15 , 36 ]. Although it has been suggested that this reduction regarding the number of admissions during the pandemic in comparison to the pre-pandemic timeframe in patients with cardiovascular diseases and especially PAD patients was probably multifactorial, the most important key factor might be patients’ fear for virus transmission and SARS-CoV-2 contagion as well as COVID-19 infection arising from doctor-patient contacts in the ambulatory setting and/or in particular at the hospitals [ 8 , 14 ].…”

“…Although it has been suggested that this reduction regarding the number of admissions during the pandemic in comparison to the pre-pandemic timeframe in patients with cardiovascular diseases and especially PAD patients was probably multifactorial, the most important key factor might be patients’ fear for virus transmission and SARS-CoV-2 contagion as well as COVID-19 infection arising from doctor-patient contacts in the ambulatory setting and/or in particular at the hospitals [ 8 , 14 ]. This fear of hospital-acquired COVID-19 infection is one of the main reasons for patients to avoid hospital admission and thus, PAD diagnostic as well as adequate management is hampered and delayed [ 14 , 15 ]. Another key factor is the change regarding the focus of the health care service [ 14 , 15 ].…”

“…A few studies revealed that admitted PAD patients during the COVID-19 pandemic showed increased severity of PAD and more acute complications [ 14 , 15 ]. This little and limited attention regarding the impact of the COVID-19 pandemic on the admission numbers of PAD patients is contrary to the large burden of PAD and the influence of PAD on morbidity and mortality worldwide [ 16 , 17 ].…”

Impact of the COVID-19 Pandemic on In-Patient Treatment of Peripheral Artery Disease in Germany during the First Pandemic Wave

“…In a retrospective single-center study in Switzerland, Trunfio et al demonstrated a similar effect, with an overall decrease in patient numbers but a relative increase in Fontaine stages III-IV to 66.7% during the first wave compared with 47.3% during the same periods in 2018 and 2019. Equally impressive was the relative increase in the proportion of patients with acute limb ischemia, i.e., a vascular emergency, from 24.6% to 47.5% [ 12 ]. In contrast, in their evaluation of two large hospitals in the Netherlands, Exelmans et al observed no significant decrease in the number of patients treated throughout 2020, but a relative increase in higher PAD stages and acute limb ischemia with a subsequent increase in major amputations [ 15 ].…”

“…In addition, there was the uncertainty and fear of the patients themselves, which is why they often avoided going to the doctor or even to hospital in order not to expose themselves, supposedly unnecessarily, to the risk of infection. This is also reflected in the fact that the adequate and thus vital control of risk factors has relevantly deteriorated [ 12 ]. But how did the 2020 pandemic, particularly the first surge from mid-February to mid-May, ultimately affect inpatient treatment of PAD patients in Germany compared to the previous year?…”