key: cord-1032742-hq7t04lu
authors: Bissacco, Daniele; Grassi, Viviana; Lomazzi, Chiara; Domanin, Maurizio; Bellosta, Raffaello; Piffaretti, Gabriele; Trimarchi, Santi
title: Is there a vascular side of the story? Vascular consequences during COVID‐19 outbreak in Lombardy, Italy
date: 2020-10-04
journal: J Card Surg
DOI: 10.1111/jocs.15069
sha: 6d5005f8e67f74397e9ca00b9c24d82222942e04
doc_id: 1032742
cord_uid: hq7t04lu

BACKGROUND: Lombardy, in the northern Italy, was one of the most affected region in the world by novel coronavirus COVID‐19 outbreak. Due to the dramatic amount of confirmed positive cases and deaths, all clinical and surgical hospital departments changed their daily activities to face emergent pandemic situations. In particular, vascular surgery units reorganized their role and priorities for both elective and urgent patients requiring open or endovascular interventions. MATERIAL & METHODS: This brief review summarizes organization of vascular Lombardy centers network adopted during pandemic period and clinical evidences published so far by regional referral and nonreferral hospitals in terms of vascular surgery and medicine implications in COVID‐19 positive or negative patients managements. RESULTS: Different patterns of disease were described during phase 1 COVID‐19 outbreak in Lombardy region, with major attention in pheriperal artery disease and venous thrombosis. CONCLUSION: COVID‐19 infection seems to be not only a pulmonary but also a vascular (arterial and venous) disease. Further study are necessary to described mid and long‐term outcomes in COVID‐19 vascular patients population.

In particular, Lombardy-about 10.6 millions of habitants, in northern Italy-was the most affected region in Italy ( Figure 1A) , with more than 92,000 confirmed cases (about 38% of all cases in Italy) and more than 16,400 confirmed deaths (about 48% of all Italian deaths, Figure 1B ). 2 Severity and mortality rate associated with COVID-19 pneumonia have led to an extraordinary effort by all the medical and scientific communities, to provide the best operative support in terms of basic research, rapid diagnosis, and prompt treatments. [3] [4] [5] Vascular specialists and vascular surgeons were not spared, treating not only vascular patients but also COVID-19 patients, irrespective of vascular comorbidities or complications.

Therefore, in this dramatic scenario, vascular surgery units and vascular services have modified their daily clinical and surgical activities to face the pandemic situation. In particular, a rapid increase of intensive care unit (ICU) and ward beds were provided for managing patients positive to the virus, with the creation of dedicated pathways for COVID-19 confirmed or suspected cases, for both hospitalized or outpatients.

Italy-and Lombardy as one of the first regions-was the first country in the word that restructured its vascular surgery units' network to contrast the COVID-19 outbreak. In fact, on March 8th, 2020, Lombardy Regional Council Ordinance imposes to adopt necessary and special actions due to epidemiological emergency, to provide practical indications for all healthcare operators. 6 Healthcare system reorganization passed through four steps:

− Introduction of a "Hub and Spoke" system. In the case of Vascular and Cardiovascular Surgery, a taskforce of vascular specialists was created, as described by Bonalumi et al. 7 In this exhaustive report, the institution of Hub hospitals for urgent and emergency patients, supported by satellite Spoke hospitals, was detailed described. In brief, 4 Hub and 15 Spoke hospitals were identified in Lombardy. Hubs guaranteed 24-h emergency service, with the possibility to perform at most three surgical procedures at the same time. Spoke hospitals were invited to transfer urgent cases to their referral Hub center, to potentially concentrate their efforts on COVID patients' treatments only.

Treatment recommendations and criteria for each vascular and cardiac disease that required surgical treatment were described, categorizing patients as presenting with urgent and nonurgent condi- those patients recovered in ICU patients and already receiving antithrombotic prophylaxis. In these three experiences in Lombardy, the incidence of emergent/urgent aortic lesions necessitating intervention was as low as 10%-15%. Such data was then confirmed by a currently unpublished survey conducted among about 90% of vascular centers in Lombardy, which showed a 13% incidence of cumulative thoracic and abdominal aortic diseases in the COVID-19 acute phase 1 (March 8th-May 3rd, 2020). 9 In this time, another important issue was related to vein thrombosis, in particular deep vein thrombosis (DVT)-that was detected as a not-so-rare condition in COVID-19 patients (23% for patients intubated in ICU and 8% for patients breathing spontaneously, on 108 COVID-19 cases). 10 

The entity of the COVID-19 pandemic in the Lombardy region was of primary relevance, resulting, as consequence, in a real-word vascular surgery experience, with no unconcreted hypothesis or very preliminary results. The number of patients affected in this area leads to significantly different vascular treatments and results performed in the COVID-19 population, which is associated with increased mortality. 8, 9 It is evident that during the pandemic period the number of patients presented at referral hospitals with severe or not-severe ALI or critical limb ischemia (CLI) was increased when compared with the same period in 2019. This was true also in other Italian areas or European and non-European countries, although reported as single cases or limited case series. 12, 13 Even though it was stated an increased peripheral artery disease (PAD) rate, no significant mention of ALI or CLI is reported in other large-scale series describing inhospital or ICU patients with COVID-19. 11, 14, 15 Only Klok et al. 16 reports two cases of peripheral arterial embolism in 184 ICU patients with confirmed COVID-19 infection. Unfortunately, no details on specific characteristics regarding affected arteries, treatments adopted, and postoperative outcomes are provided.

An important point to be taken into account is that the relative increase of arterial thromboembolism during the pandemic period could be also caused by some biases and confounding factors, like the concentration of all ALI or CLI emergencies in Hub centers, delay in ER presentation attributable to impose lockdown, old patients' age and fear in approaching hospitals because of high contamination risk.

In this setting, nonoptimal treatment of patients-particularly outpatients with arterial ulcers, diabetic ulcers, and/or chronic CLI-with other diseases than COVID-19 led to more serious and sometimes irreversible clinical status at the first visit. This statement was also supposed by a brief Italian report that emphasizes not only a quantitative increase in ALI or CLI patients but also an increase of clinical severity in PAD, resulting in an augmented rate of major amputations. 17 Comparable analysis and hypothesis were found in case of admissions and mortality rate for acute myocardial infarction (AMI) in pandemic-2020 and 2019 same periods. 18 In particular, although the admission rate was significantly reduced during the COVID-19 pandemic across Italy, mortality and complication rates were increased, probably for the same reasons described above. Furthermore, also for a major cardiovascular event such as acute type A aortic dissection, a multicentre observational study conducted in New York, described a significant decrease in the monthly surgical case volume (from 12.8 ± 4.6 cases/month before-COVID to 3.0 ± 1.0 cases/month after-COVID). 19 As the main causes for this ob- Regarding postoperative outcomes, a higher rate of unsuccessful revascularization (29.4%), reintervention (13.0%), and in-hospital mortality rate (40.0%) were reported. 8, 21 As the authors claimed, poor outcomes were probably due to the situation of "desert foot" during completion angiography after selective thrombectomy, with scarcity in forefoot microcirculation. The increased PAD severity (Rutherford classes III and IV) may be another risk factor to explain postoperative complications. Although an augmented ALI and reintervention rates were observed in patients with COVID-19, apparently no angiographic and in vivo macroscopic differences were described in thrombus specimens, as mentioned, with a gelatinous consistency. 8 Despite nonunivocal results and the need for further studies to assess the real incidence of ALI, CLI, and PAD in COVID-19 patients, it is undoubtful that the novel coronavirus infection is associate with hypercoagulability and thrombogenic state with multiple direct and indirect cardiovascular complications. [22] [23] [24] In particular, severe endothelial injury, widespread thrombosis with microangiopathy, alveolar-capillary microthrombi, and new vessel growth were found in COVID-19 patients' lung autopsy. 25 These pathological features, if affected also peripheral limb circulation, may aggravate PAD ( Figure 5 ) or may generate thromboembolic disease in non-PAD patients. 11 Furthermore, the chronic infectious state may contribute directly or-more likely-indirectly, to postoperative complications after vascular surgery treatments, as mentioned for other viruses, like during human immunodeficiency virus (HIV) infection. 26, 27 Regarding peripheral venous complications, other studies confirm an augmented DVT rate in patients with COVID-19, particularly in ICU cases. 16, 28, 29 Despite this, also for venous thromboembolic complications there could be confounding factors that may hide the real incidence of DVT specifically caused by COVID-19 disease: immobility, particular in ICU patients, an infectious state with coagulation disorders due or not to liver impairment, extracorporeal circulation necessary for supporting ventilation, heart pump disorders, disseminated intravascular coagulopathy, multiple organ dysfunction syndromes, dysregulation in corporeal fluid balance with In our region, hospital and daily practice organization had dramatic modifications, with the creations of Hub and Spoke centers for delivering cardiovascular care. However, although this organization was nicely and promptly organized, in some sense appeared undue because the total number of such emergencies was limited, and several other hospitals were able to continue the surgical program because of enough own dedicated resources. Nevertheless, the regional organizing program and the activity effectively performed during the COVID-19 phase 1 represented an important stress test for the entire health system and the cardiac and vascular surgical community in Lombardy.

Coronavirus disease (COVID-19) dashboard

Covid-19 Italy Situation Report. Fondazione Cuore Domani e Società Italiana di Chirurgia Cardiaca (SICCH)

COVID-19 and Italy: what next?

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A call to action becomes practice: cardiac and vascular surgery during the COVID-19 pandemic based on the Lombardy emergency guidelines

Acute limb ischemia in patients with COVID-19 pneumonia

Pattern of vascular disease in Lombardy, Italy, during the first month of the COVID-19 outbreak

The "venous perspective" in Lombardia (Italy) during the first weeks of the COVID-19 epidemic

Venous and arterial thromboembolic complications in COVID-19 patients admitted to an academic hospital in

Acute limb ischaemia in two young, non-atherosclerotic patients with COVID-19

Acute upper limb ischemia in a patient with COVID-19

Features of 20 133 UK patients in hospital with covid-19 using the ISARIC WHO Clinical F I G U R E 5 Peripheral (A) and pulmonary (B) condition in a patient with COVID-19 pneumonia and acute limb ischemia. Note the "desert foot" (asterisk) condition after thrombectomy

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An increased severity of peripheral arterial disease in the COVID-19 era

Reduction of hospitalizations for myocardial infarction in Italy in the COVID-19 era

The COVID-19 pandemic and acute aortic dissections in New York

Vascular surgeon discomfort in a pandemic setting

Vascolare Lombarda nell'epidemia da Covid 19

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Covid-19 and thrombosis: what do we know about the risks and treatment?

Coronavirus disease-2019 (COVID-19) and cardiovascular complications

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Large vessel adventitial vasculitis characterizes patients with critical lower limb ischemia with as compared to without human immunodeficiency virus infection

Large artery vasculopathy in HIVpositive patients: another vasculitic enigma

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Prevalence of venous thromboembolism in patients with severe novel coronavirus pneumonia

Is there a vascular side of the story? Vascular consequences during COVID-19 outbreak in Lombardy, Italy

The authors declare that there are no conflict of interests.

https://orcid.org/0000-0003-0724-0237Gabriele Piffaretti https://orcid.org/0000-0002-9906-4658