Vascular Surgery Practice Guidelines during COVID-19 Pandemic in a Setting of High Work Volume Against Limited Resources: Perspective of a Developing Country

Abstract

Background The situation of coronavirus disease 2019 (COVID-19) pandemic in the Indian subcontinent is worsening. In Bangladesh, rate of new infection has been on the rise despite limited testing facility. Constraint of resources in the health care sector makes the fight against COVID-19 more challenging for a developing country like Bangladesh. Vascular surgeons find themselves in a precarious situation while delivering professional services during this crisis. With the limited number of dedicated vascular surgeons in Bangladesh, it is important to safeguard these professionals without compromising emergency vascular care services in the long term. To this end, we at the National Institute of Cardiovascular Diseases and Hospital, Dhaka, have developed a working guideline for our vascular surgeons to follow during the COVID-19 pandemic. The guideline takes into account high vascular work volume against limited resources in the country. Methods A total of 307 emergency vascular patients were dealt with in the first 4 COVID-19 months (March through June 2020) according to the working guideline, and the results were compared with the 4 pre–COVID-19 months. Vascular trauma, dialysis access complications, and chronic limb-threatening ischemia formed the main bulk of the patient population. Vascular health care workers were regularly screened for COVID-19 infection. Results There was a 38% decrease in the number of patients in the COVID-19 period. Treatment outcome in COVID-19 months were comparable with that in the pre–COVID-19 months except that limb loss in the chronic limb-threatening ischemia patients was higher. COVID-19 infection among the vascular health care professionals was low. Conclusions Vascular surgery practice guidelines customized for the high work volume and limited resources of the National Institute of Cardiovascular Diseases and Hospital, Dhaka were effective in delivering emergency care during COVID-19 pandemic, ensuring safety of the caregivers. Despite the fact that similar guidelines exist in different parts of the world, we believe that the present one is still relevant on the premises of a deepening COVID-19 crisis in a developing country like Bangladesh.

The impact of the COVID-19 pandemic on vascular surgery: Health care systems, economic, and clinical implications

“…Coagulopathy in COVID-19 results from endothelial damage, complement activation, and cytokine release and can cause acute limb ischemia (ALI) by worsening a chronic vasculopathy or causing peripheral embolization from newly formed thrombus 54 , 55 , 56 . Numerous studies have demonstrated the increased incidence of ALI during the pandemic and the devastating associated outcomes 56 , 57 , 58 , 59 , 60 . Multiple studies reported an increased ALI incidence during the pandemic in Lombardy, Italy, one of the hardest COVID-19 struck regions in the world; 305 referred vascular surgery patients at the peak of the pandemic were analyzed, and although only 21% were found to have COVID-19, two-thirds of ALI cases occurred in COVID-19 positive patients 56 , 59 .…”

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

“… 23 Several articles had also reported an increase in major amputation rates during the COVID-19 pandemic. 26 , 27 , 37 , 38 This occurrence could be a result of delayed case presentation as discussed earlier, or can be due to a change in surgical practice. Limb salvage can be a resource-intensive process involving long hospitalizations coupled with multiple re-interventions.…”

“…A total of 19 articles had reported changes in the conduct of emergency and elective VS cases in respective institutions. 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 In summary, all articles reported continuation of emergency VS cases such as ruptured AAAs, and deferment of non-urgent elective VS cases such as revascularization for claudicants and varicose veins. There was some inter-institutional variation between the type of VS cases that proceeded or were deferred.…”

“…Bashar AHM et al provided an insight into the conduct of VS cases during the COVID-19 pandemic. 38 Lastly, Wang J et al also reported the deferment of non-urgent elective VS cases in China, but did not provide additional data. 39 …”

“… 23 , 27 Lastly, Bashar AHM et al similarly reported a decrease in limb salvage rate from 83.6% to 72.4% for patients presenting with CLTI during the COVID-19 pandemic compared to a pre-pandemic period. 38 …”