Learn from the First Wave to Surf the Next One Optimally.

Kahlberg et al. report on the experience of four centres dedicated to vascular surgery during the first seven weeks of the COVID-19 outbreak in Lombardy, Italy, one of the areas most affected by the pandemic in Europe. The authors present details of a specific infection control arrangement centred on having four vascular surgery hubs associated with a number of afferent centres. They provide a very interesting picture with two main findings: (1) acute limb ischaemia (ALI) was the most frequent vascular disease requiring surgical treatment; and (2) patients with associated COVID-19 had a fourfold increased risk of death and a threefold increased risk of major adverse events (MAEs).

Since the start of the outbreak, the European Society for Vascular Surgery alerted our community to the necessity of providing dedicated research programmes to provide optimal care to patients. ,

In this area of Europe, the majority of the centres postponed elective cases to leave room for the huge wave of admissions requiring free Intensive Care Unit (ICU) beds and to transfer operating room staff to ICUs. Interestingly, a paper from another affected area of Italy showed that performing elective procedures with specific patient management was feasible.

Regrettably, it was not possible for the authors to compare the activity during this period with the activity they had seen in the same period in 2019. For example, it would have been interesting to compare cases of ALI: ALI could have been more frequent, presentation could have been different because of associated thrombotic disorders, or it may have been diagnosed later because patients presented later owing to a fear of being infected by COVID-19 in hospital. In the same way, it would have been interesting to know whether the authors treated fewer patients for ruptured abdominal aortic aneurysms because of the infection risk. The fact that only one patient was treated for aortic infection in this area might mean it was under diagnosed in a period where fever equalled COVID-19 infection in physicians' minds.

Another important message provided by this study is the higher mortality and MAE rates in patients with COVID-19. Unfortunately, it was not possible to distinguish patients who came directly to the hospital for treatment for their vascular disease from patients who were already in ICUs and who presented with ALI as a comorbid association with COVID-19 disease. Finally, we would expect that patients who were considered too frail to benefit from aggressive treatment because of COVID-19 infection only received medical treatment.

To conclude, this paper actually contributes to the search for optimal vascular disease management during COVID-19. The pandemic is still here, patients might come too late, and patients treated for vascular diseases are at risk of MAE if infected by COVID-19. While Europe is facing the second wave, we actually learned how to improve in hospital patient flows and management during the first wave.

However, the specific progression of the pandemic, with successive waves requiring cancellation of elective cases followed by rescheduling as we did in the summer, requires new research programmes. Firstly, we should be able to provide recommendations on priorities regarding cancellations and rescheduling depending on the level of hospital and staff resources, including medical and ethical factors. Secondly, the impact of the COVID-19 pandemic on vascular disease management must not only be evaluated according to in hospital data, but also with regard to strong epidemiological studies of the overall management of the patients. Recommendations should be provided not only to vascular surgery units, but also to general practitioners, to decrease the risk of a loss of chance for these patients. It will be also necessary to evaluate the overall consequences on this population to know how many lives and limbs are lost to save one patient with COVID-19 in the ICU.