key: cord-0727247-98sprob9 authors: Faggioli, Gianluca; Chakfe, Nabil; Imray, Chris title: Maintaining safe elective aneurysm surgery in the COVID-19 era date: 2021-07-02 journal: Eur J Vasc Endovasc Surg DOI: 10.1016/j.ejvs.2021.06.033 sha: f6e0dba27e3e2ced444f6c4009b89c709370aae5 doc_id: 727247 cord_uid: 98sprob9 nan The respiratory syndrome COVID-19 has had a devastating effects on health, economy and social life worldwide. The health care system of industrialized countries has been at times submerged by the pandemic, leading to some of the most challenging choices in health resource distribution experienced by this generation. During local Covid19 prevalence surges, access to theatres and intensive care facilities for all but the most urgent surgery has been severely restricted. The workforce and intensive care have been redeployed to deal with flood of Covid19 cases. Associated with this limited access to elective theatre, disease specific case prioritization has been required. Society and healthcare providers tend to be very aware of the need to perform early surgery for cancer diagnoses, and the associated high morbidity and mortality of vascular patients less well recognized. The high mortality of vascular patients infected with Covid19 and particularly the risk of pulmonary complications was not widely understood at the start of the pandemic; moreover, there was a high geographical variability in the severity of the COVID-19 distribution, and a standardization of the hospital strategies was not possible. [1] [2] [3] [4] Data from the National Vascular Registry of the UK show that postoperative outcomes aremortality was negatively influenced in the first pandemic wave by intervening infection with SARS-Cov-2, increasing from 2.9% to 6.1% for patients without respiratory complication and from 27.9% to 38.2% for those with respiratory complications 5 Although careful planning and organization of dedicated vascular units has allowed to maintain in some instances a regular activity1 the problem of the treatment of asymptomatic abdominal aortic aneurysms (AAA) urged a number of considerations and studies. The treatment of asymptomatic, intact AAA obviously aims to prevent rupture and mortality and the thresholds to achieve the most advantageous benefit/risk ratio are well established in the literature,6,7 . The onset of the pandemic has forcedly changed this scenario, since a series of issues should be considered under these circumstances, as listed below. 1. The risk of AAA rupture should be balanced against the risk of mortality in case of COVID-19 infection, which is approximately 0.6% in patients <60 years and 7% in those >70 years 8. This adjunctive risk should be considered when admitting an asymptomatic AAA patients in a surgical ward, where the risk of being infected by COVID-19 is definitely greater compared with a protected environment outside the hospital. Generally speaking, patients with suspected COVID-19 (fever, cough or radiological signs of pneumonia) should be isolated in dedicated rooms and submitted to multiple nasopharyngeal swabs to reduce the risk of false negative results. Elective operations should be executed only in negative patients. All patients admitted to hospital should wear surgical masks at all times. Emergency patients should be considered positive for COVID-19 until differently proven and directed to dedicated pathways, wards and operating rooms. Any patient with COVID-19 infection or suspicion of infection, should be treated by protected physicians, wearing double surgical cap, FFP2 mask, facial shield, and complete body and leg coverage.1 However, the risk of COVID-19 infection varies significantly among the geographical areas, single hospitals and the status of the pandemic curve, therefore quantitative considerations cannot be made in this sense. Strategies for COVID-19 prevention varied in different hospitals with effective results, however no generalization can be made in this sense 1, 4, 9 Only generic recommendations can be suggested in order to wisely determine the most advantageous conduct in terms of patient benefit, however safety of in-hospital personnel and conversely to admitted patients will not be further an issue with the progression of the vaccination campaign, which will privilege this population 2. Resources should be reserved for COVID-19 patients as much as possible. According to the Royal College of Surgeons10, 4 priorities need to be preserved during the emergency phase: For the individual surgeon this means to maintaining at least sub-specialty emergency surgical capacity. Outside the emergency setting, when facing with an intact, asymptomatic AAA, priority should therefore be given to standard EVAR procedure where the anatomy allows, as suggested by ESVES guidelines in the ordinary setting 7 in order to preserve limited Intensive Care Unit (ICU) resources for more urgent situations. This is in contrast with the general recommendation of NICE guidelines, where preference is given to open aneurysm repair, which almost inevitablyoften needs postoperative intensive care.11 Since EVAR can be performed under local or loco-regional anesthesia, it can be continued also during the pandemic; the decision about postponing the AAA treatment is therefore to be addressed almost exclusively to cases anatomically unsuitable for EVAR. Generally speaking, the American College of Surgeons recommends to not postpone ruptured or symptomatic aneurysm, postpone if possible those >6.5 cm and definitely postpone those < 6.5cm 12 In the UK a higher threshold of 7.0 cms was chosen 13. Different protocols have been employed in the vascular centers worldwide. At the University of Bologna, for example, AAA were electively treated when >6cm or enlarging more than 1 cm/year. For that reason the number of treated AAA in the month of March 2020 halved compared with the previous year 8 vs 16 in 2020 compared with 20191 Similar indications were followed in another Italian center13 In other centers, AAA continued to be treated when indicated, irrespective of their size 3, 15 A key question that should be kept in mind when in doubt about postponing the AAA treatment is reported in the paper of Tan et al.: "If surgery is denied, will this patient be admitted with a life-or limb-threatening condition that will consume more resources if performed in an emergency setting?" The answer to this dilemma cannot be categorized, however may address the vascular surgeon to a reasonable choice 16. That dilemma has not an easy solution; however, it can be the key question for driving the physician toward a reasonable choice If AAA repair can be reasonably postponed safely, greater resources can be dedicated to other COVID-19 patients, as seen above. However, the time of delayed treatment, the possible pandemic evolution and the impact of the vaccine campaign are not yet defined; all of these issues are of outmost importance to define the shift of assets in favour of COVID-19 patients. Postpone AAA surgeries implies ethical considerations. Who should decide? The physician in charge only? We should favour multidisciplinary meeting with a systematic review of all cases previously planned in order to not only consider the diameter but the overall patient with all the necessary transparency. Each individual patient should be postponed with a grade of emergency that is considered for replanning the procedure. The pandemia we thought or hoped to be temporary evolved in successive waves with some windows with recovered facilities must be used to treat patients with the highest emergency grade. The other ethical point is to never forget patients and to keep connected to them in order to explain what is the best for them and to counteract legitimate fear to leave their home to the hospital. Another aspect to be considered is the risk of thrombotic complications which seems to be increased by COVID-19 infection. Although rare, catastrophic complications such us aortic graft thrombosis have been reported during the pandemic phase and should be taken in account. 17 3. Psychological aspects. One factor to be considered is that during the COVID-19 pandemic preoperative consultation between doctors and often even with patients may occur not face to face but through web meetings or by telephone. 18 This may alter in some way the relationship between patient and physician, leading to a more difficult comprehension of the type and implication of the treatment. Another issue to be considered is the psychological effect of patients who were surveilled for their aneurysm <5.5 cm in diameter. If the threshold is reached during the pandemic phase, the patient suddenly become informed that the benefit of treatment is now shifted beyond 6.5 cm or even 7 cm. This may lead to a fall in the trust toward the physician and the medical science, particularly if the patient belongs to a screening program, and care should be taken to explain in detail the reason for a shift in the therapeutic strategy. Therefore, the possibility of adding new variables Iin the vascular registries creening program should be continuously considered 19 The concern about COVID-19 infection in the general population leads also to possible abandonment of the surveillance program by the patient: participants in the UK National Abdominal Aortic Aneurysm Screening Programme declared to be willing to attend the program in only 59% of cases, vs a 90% attendance rate in the previous years. This was mainly due to the concern of being infected by COVID-19, since as much as 42.5% of them were more concerned about catching COVID-19 than to have a rupture of their aneurysm. 20 In this context it is reasonable to anticipate an increase in the rate of ruptured aneurysm. If this has not been observed yet it is probably due to the relatively short time of the pandemic. Future studies will analyze the shift in the incidence of ruptured AAA during and after the pandemic. One of the most neglected effects of the emergency pandemic phase is the effect on the surgical training. Since this phase is lasting several months, a significant reduction on the theoretical and practical surgical training programs has occurred: as seen elective procedures may diminish Iin most centers; overall, different types of emergencies can occur with significant change in the usual planning and follow-up procedures. All of this will lead to future effect on the trainees professionalism which will be necessarily analyzed. 21 As seen, several aspects should be considered in the treatment of asymptomatic AAA during the COVID-19 pandemic. If a fast-track AAA diagnosis and treatment process can be followed, patients can be continued to be treated, obviously with all the necessary precautions to avoid COVID contaminations of both patients and health professionals 1. AAA requiring difficult procedures, expected prolonged ICU admission should be delayed in favourfavor of interventions feasible under local anesthesia, with simple postoperative controls and short hospital stay 22. In summary, many consideration can be drawn after one year on the effect of the COVID-19 pandemic on safe vascular surgery treatment for not urgent situation such as asymptomatic AAA. The principles listed of the latter can be extended also to all non-urgent vascular procedures, as depicted in the Box below. In general, similar to the original UK Vascular Society and GIRFT (Getting It Right First Time) CV19 advice. , 23,24 Units must interpret the general advice given and also take into account their local situation. Shared decision making with patients, multidisciplinary team meeting and documentation should recognize that 'time intervals may vary from usual practice and may possibly result in greater risk of an adverse outcome due to progression or worsening of the condition, but we have to work within the resources available locally and nationally during the crisis', as stated in the National Health Service England guidance on surgical prioritisation during Covid-19. 25 Is it Possible to Safely Maintain a Regular Vascular Practice During the COVID-19 Pandemic? Early experience in the COVID-19 pandemic from a vascular surgery unit in a Singapore tertiary hospital Vascular Surgery During COVID-19 Emergency in Hub Hospitals of Lombardy: Experience on 305 Patients Strategies and reccomendations for the safe implementation of vascular surgery during the pandemic period of novel coronavirus pneumonia The Society for Vascular Surgery practice guidelines on the care of patients with an abdominal aortic aneurysm European Society for Vascular Surgery (ESVS) 2019 Clinical Practice Guidelines on the Management of Abdominal Aorto-iliac Artery Aneurysms Estimates of the severity of coronavirus disease 2019: a model-based analysis COVID-19 and vascular surgery at a central London teaching hospital Royal College of Surgeons Guidance for surgeons working during the COVID-19 pandemic Treatment of Aortic Aneurysms During the COVID-19 Pandemic: Time to Abandon the NICE Guidelines Available at:www.facs.org/covid-19/clinical-guidance/elective-case/vascular-surgery, 13. The Vascular Society for Great Britain and Ireland. COVID-19 Virus and Vascular Surgery; 2020 COVID-19 Impact on Vascular Surgery Practice: Experience From an Italian The Italian USL Toscana Centro model of a vascular hub responding to the COVID-19 emergency Early experience in the COVID-19 pandemic from a vascular surgery unit in a Singapore tertiary hospital Acute Thrombosis of an Aortic Prosthetic Graft in a Patient with Severe COVID-19-Related Pneumonia Ann Vasc Surg Raghvinder Pal Singh Gambhir, M Time to pause, to think, and to recalibrate after COVID-19 The Need of Research Initiatives Amidst and After the Covid-19 Pandemic: A Message from the Editors of the European Journal of Vascular and Endovascular Surgery Willingness of patients to attend abdominal aortic aneurysm surveillance: The implications of COVID-19 on restarting the National Abdominal Aortic Aneurysm Screening Programme Br J Surg Distance learning for vascular surgeons in the era of a pandemic Routine in an Italian high volume vascular surgery during the COVID -19 era. How the pandemic changed the vascular surgery daily practice