Coronavirus has been impacting the way we live and practise since the beginning of 2020. Western Australia has been relatively less affected directly by the virus. As case numbers continue to rise here, it is timely to consider the impact of COVID-19 either directly or indirectly on vascular patients, based on interstate and international experience plus WA Health modelling and planning.
Does COVID-19 increase the risk of acute vascular presentations and how might we best serve patients afflicted with vascular pathology?
Interstate and international experience
Talking to colleagues from interstate, it is reasonable to expect that the volume of elective vascular surgery work in public hospitals will significantly reduce, if not completely stop. Private hospital workload appears to have continued, albeit with a 50% decrease in elective work.
Fortunately, most elective surgical delays can be done so safely, although anecdotally, increased numbers of acute presentations of all vascular pathologies (e.g., ruptured aneurysms, ischaemic limbs, or thrombosed renal access) has been noted.
Telehealth reduces in-person consultations but has limitations. As case numbers go down, we can expect an increase in workload as patients feel comfortable to seek attention for their ailments, and a resultant secondary strain on healthcare providers. A 90% backlog accounting for eight months of work was reported in the US.
International literature backs up the anecdote. Worldwide practice has changed – to reduce the volume of cases being treated, and to target reduced length of stay, rather than the best practice approach for the individual.
During the 2020 lockdown period in the Netherlands, surgeons reported a statistically significant increase in advanced tissue loss, resulting in a tripling of the annual number of amputations.
In the US, vascular surgeons reported high rates of COVID exposure, reduced ICU bed availability, and changes in consulting practices with increased telehealth or redeployment. Again, in the US, national numbers of acute limb ischaemia revascularisations increased in 2020, while elective and emergency aortic and carotid intervention decreased (likely from decreased access to health care rather than decreased disease incidence).
Does COVID increase the risk of acute vascular presentations?
The reason for the increase in acute vascular presentations is going to be complex. Proposed theories include delayed presentations due to health care avoidance, reduced case volumes in diagnostic and treating facilities, and delays in treatment due to reduced access. We also know that COVID infection increases thromboembolic risk even in patients with mild symptoms.
Venous and arterial complications are approximately 8%, even when a patient is on VTE prophylaxis, and patients with raised D-dimer are at a high risk of developing symptomatic thromboembolic events. Be aware that arterial thrombotic events can be the presenting manifestations of COVID.
From mid-March and a week later in private hospitals, for a period of seven weeks, all category 3 cases will be postponed, and only urgent category 2 cases will proceed with a cap on total numbers yet to be confirmed. The peak of cases is likely to occur within this time frame, on a daily basis it is expected we will see more than 10,000 cases a day, over 400 hospital beds occupied, and 56 ICU beds occupied.
The caveat to this modelling is that the state’s high number of double-dose and booster vaccinated individuals will hopefully see lower case numbers in hospital than predicted. Hopefully our patients might be less affected than our interstate and international colleagues experienced.
Managing vascular pathology
We all know how difficult a vascular assessment can be via telehealth, so keep a close eye on patients who have significant risk factors for atherosclerosis or aneurysms, and consider the increased thrombotic risk that coronavirus poses to patients.
The vast majority of vascular surgeons I’ve spoken to have action plans for continuing to consult during the pandemic and will be able to triage and manage the patient accordingly. A telehealth consultation is an opportune time to screen the vasculopath regarding symptom deterioration, and surveillance.
If their symptoms have deteriorated or they’ve not seen a surgeon for more than a year, don’t hesitate to refer.
Key messages
- Internationally there has been a negative impact on vascular health due to COVID restrictions
- Arterial thrombotic events can be a presenting feature of COVID infection
- Keep a close watch on patients with vascular pathology and refer as needed.
– References available on request
Author competing interests – nil