Adapting vascular care amidst a pandemic: Considering COVID-19 and looking forward

The coronavirus disease 2019 (COVID-19) pandemic introduced unprecedented challenges and urgent deviations to clinical practice in nearly every corner of healthcare. In the initial weeks of the pandemic, a hurried redistribution of resources to affront the global crisis caused chaos and understandable deficiencies in many aspects of care, particularly for those not directly impacted by COVID-19. Virtual medicine was widely introduced to maintain contact with our patients, although it seemed inadequate to care for the most vulnerable. After the first wave of COVID-19 waned, it took several months to recover from backlogs of procedures and in-person care.

For patients with peripheral artery disease (PAD), many of whom require ongoing vascular evaluation, testing, and treatment, the pandemic left many at risk for serious complications. Delayed or inaccessible procedural care likely produced a measurable indirect toll of COVID-19. So, just how were procedural volumes and in-hospital outcomes impacted by the pandemic? And, perhaps more importantly, might the lessons learned about pandemic vascular care better prepare us for a future wave of COVID-19 or for the next pandemic?

To help gain that perspective, Lou and colleagues present a timely retrospective of the impact of COVID-19 on lower extremity revascularization and amputation procedure volumes from the Society for Vascular Surgery’s Vascular Quality Initiative (VQI) registry. ¹ The work provides scope and validation of the impact on vascular care incurred in the initial months of the pandemic. The study is robust, including an analysis of 57,181 patients from 147 US and Canadian centers. As expected, overall vascular procedure volumes fell by over 35% in the early weeks of the pandemic compared to volumes recorded in the months before the COVID-19 surge. The work also highlights the differential impact on elective versus urgent or emergent procedures. There were also important differences in characteristics of the population during COVID-19, many of whom presented with diagnoses requiring urgent vascular treatment.

As COVID-19 surged, rates of elective procedural care declined sharply, mostly due to a reduction in revascularization of claudication. ¹ Those patients presenting for vascular care during the surge were marked by non-White race and higher rates of diabetes, end-stage renal disease, and a history of heart failure. Chronic limb-threatening ischemia (CLTI) and acute limb ischemia (ALI) accounted for a greater number of in-hospital procedures during the surge, which were also marked by an increased proportion of non-elective procedures for lesions of the highest anatomic complexity. ALI and uncontrolled infection accounted for a higher proportion of amputations during the pandemic surge, which also found increased rates of above-knee amputations and fewer minor amputations compared to baseline. As might be expected, adjusted in-hospital mortality was greater for patients with claudication and ALI into the surge and postsurge periods. Interestingly, a similar mortality trend was not seen for those with CLTI.

The report from Lou and colleagues suggests that whereas all patients with vascular disease were susceptible to complications of the COVID-19 viral illness, many more were left exposed to the indirect healthcare circumstances created by a pandemic. In our experience, treatment of CLTI during the healthcare crisis led to conspicuous challenges of multidisciplinary care, including reduced access to home healthcare, deferral of nursing resources, less frequent monitoring and treatment, and strain on psychosocial dynamics. Such factors are challenges in the care of patients with CLTI even outside of a pandemic. Though these issues are not easily addressed with virtual healthcare alone, telemedicine certainly presented an opportunity to triage the highest risk patients. Some centers were capable of developing creative workflows to preserve access to vascular care despite the pandemic. ²

Perhaps the most striking findings of this VQI analysis, however, is the sharp increase in mortality rates among those with claudication. Compared to presurge, the odds of in-hospital mortality among patients with claudication increased 4.4 times in the postsurge period. ¹ Although the mechanisms for this phenomenon are not entirely clear, access to continued medical care likely suffered during the pandemic. Although reductions in procedural volume for claudication are understandable, they may also reflect a general reduction in care to these patients at otherwise high-risk for cardiovascular complications. Fortunately, the jointly developed Society for Vascular Surgery/Society for Vascular Medicine VQI registry module for vascular medicine is forthcoming. ³ This registry will fill an important void in our understanding of ambulatory care of patients with peripheral vascular disease, including those not requiring procedures, during this pandemic, and beyond.

Without question, COVID-19 created a natural experiment of contemporary healthcare on an enormous scale. Thankfully, recent circumstances of COVID-19 have improved. The report by Lou and colleague provides salient insights and prompts interesting questions about the vulnerabilities of contemporary vascular care. In studying the collateral damage from COVID-19, we have an opportunity to minimize the destruction from the next global healthcare crisis. The value of pandemic preparation, and the harm in failing to do so, is evident. Perhaps as important, the research presented here represents an opportunity, beyond countless webinars and virtual meetings, that we health professionals continue to learn from one another despite these challenging times. Looking forward, maintaining that contact with our patients and one another will continue to be a necessary and important metric of excellence in pandemic and postpandemic vascular care.