Riding the First Covid-19 Wave: Vascular Surgery Lessons from Lombardy, Italy.

COVID-19 has posed unprecedented health challenges. Despite the significant increase in understanding of the virus, and the forthcoming roll out of a global vaccination campaign, infection and death rates remain worrisome. Even the most optimistic predictions conclude that we have a long journey before us.

In the context of an acute world crisis, it is laudable that the authors have been able to coordinate a multicentre collaboration of 31 vascular departments in the Regione Lombardia, sharing information that could be crucial. Their subsequent analysis aggregates the experience of 659 urgent or non-delay vascular patients managed during the nine week “phase one” of COVID-19, of whom 121 (18.4%) were positive for COVID-19. They detected several notable trends in patients with arterial vascular pathology. For instance, peripheral arterial occlusive disease (PAOD) was the most frequent condition requiring treatment during this period, with a 2.2 times increased risk of re-thrombosis after revascularisation procedures in COVID-19 positive patients. Moreover, all admitted COVID-19 positive patients presented a 4.5 times increased risk of complications and a 7.6 times increased risk of death.

The increased risk of re-thrombosis after peripheral revascularisation proves consistent with the already established association between SARS-CoV-2 and coagulopathy. In the light of this prothrombotic state, the authors recommend the use of early and continued intravenous unfractioned heparin, in addition to performing more extensive revascularisation procedures for PAOD. Analogously, early initiation of double antiplatelet therapy (as opposed to monotherapy) may be the preferred treatment strategy in COVID-19 patients with a recent transient ischaemic attack/stroke and 50%–99% carotid stenosis. Other authors have also suggested using an increased dose of prophylactic anticoagulants in these patients, to avoid venous thrombo-embolism.

Finally, we must not forget that the reported poor outcomes are not only due to the disease, but also to the new health system related challenges created by the pandemic. Would these infected patients have had the same prognosis in a non-outbreak setting? Large ongoing studies, such as the COvid-19 Vascular sERvice (COVER) Study, and the Vascular Surgery COVID-19 Collaborative (VASCC), alongside the use of already established quality improvement registries on addition of COVID-19 status, will in due course enlarge our understanding of the specific implications of SARS-CoV-2 infection for vascular surgery.5, 6, 7 Meanwhile, this contribution sheds important light on a disease whose real nature and effects remain obscure.