The impact of the COronaVIrus Disease 2019 (COVID-19) pandemic on the clinical management of patients with vascular diseases: findings from Tier 3 of the COVID-19 Vascular sERvice (COVER) study

Abstract

Background: During the first wave of coronavirus disease-19 (COVID-19), the pressure on healthcare led to significant restrictions and rationing of available services. Globally, vascular services were forced to change clinical management for a range of common, acute vascular presentations. The COVID-19 Vascular sERvice (COVER) Study Tier 3 aimed to understand the severity and impact of those changes on vascular patient referrals and acute presentations as a result of the pandemic in a global vascular cohort. Methods: A 4-week multicentre multinational prospective observational study was launched in March 2020. Any hospital accepting urgent on-call vascular referrals during the pandemic was eligible to participate. Clinicians were asked to outline their actual management plan for each individual patient and to identify if the COVID-19 pandemic had changed their decision making. If so, clinicians then outlined their ‘ideal’ (pre-pandemic) management plan. All cases where management plans differed from that of the ‘ideal’ pre-pandemic management underwent further analysis to quantify the severity of the alteration on a scale of 1–5 (1: minor deviation in management, including imaging modality change, 5: palliation or amputation, where otherwise a patient would have been treated). Results: A total of 1,801 patient episodes from 52 centres in 19 countries were included. The most commonly referred vascular conditions were chronic limb-threatening ischaemia (n=517, 28.7%), diabetic foot infections (n=237, 13.2%) and acute limb ischaemia (n=224, 12.4%). Only 2.3% of patients had a confirmed diagnosis of COVID-19. Deviations in management from pre-pandemic treatment occurred in 34.8% of those with unruptured >5.5 cm diameter abdominal aortic aneurysms, 27.0% of people with symptomatic carotid artery disease, 17% of people with acute or chronic limb-threatening ischaemia and 12.7% of people with diabetic foot conditions. Of these modifications, 40.7% were categorised as significant (grade 3a/3b) and 38.1% as major (grade 4), such as non-operative instead of operative management of carotid and lower limb disease. Life-changing/ending plans including major amputation or palliation, where pre-pandemic patients would have been offered limb or life salvage procedures, were made in 4.9% of cases (grade 5). Lessons learnt: The results of this study suggest that the clinical disruption experienced by vascular surgery patients during the COVID-19 pandemic was largely due to redistribution of resources rather than individual patient infection. Guidelines for service modifications were adhered to, leading to significant changes in clinical management. One in five episodes of change in management were due to patient avoidance of clinical areas for fear of contracting coronavirus. If surgical hubs, with a low risk of COVID-19 infection, are to be utilised, then patient perception of the safety of these centres will be key to their success. Conclusion: The COVER Study Tier 3 was able to show that close to one in five clinical vascular management plans were affected globally during the pandemic, with a small proportion leading to life-changing outcomes.