US National Trends in Vascular Surgical Practice During the COVID-19 Pandemic

Multicenter reports suggest that emergency coronary and cerebral revascularizations have decreased in the US during the COVID-19 pandemic, prompting concerns about unmet cardiovascular care needs.^1-3 This study sought to quantify national trends in vascular surgical practice during the COVID-19 pandemic.

Monthly volumes for aortic interventions, carotid interventions, and lower extremity interventions (LEIs) from June 2018 to June 2020 were queried from the Vascular Quality Initiative, a prospectively maintained national database. The study was approved by the Stanford University institutional review board with a waiver of consent (because of the retrospective review of deidentified data) and followed STROBE guidelines for observational studies. Of 620 centers, 206 were included for continuous participation. We compared monthly procedure rates by urgency in a pandemic cohort (January 2020 through June 2020) with a historical cohort (January 2019 through June 2019) using χ² and t tests. Data analysis was completed with Pycharm version 2020.1.4 (JetBrains). A significant threshold of P < .05 was used for 2-tailed tests.

The pandemic cohort included 24 979 procedures: 14 292 LEIs (57.2%), 7475 carotid interventions (29.9%), and 3212 aortic interventions (12.9%). Patients treated during the pandemic were more likely to use Medicare as a primary insurer (carotid interventions: pandemic, 4783 [64.2%] vs historical, 5198 [53.4%]; aortic interventions: pandemic, 2070 [64.4%] vs historical, 2459 [54.4%]; LEIs: pandemic, 8422 [58.9%] vs historical, 8830 [49.8%]; all P < .001) (Table). In the LEI cohort, patients treated during the pandemic were more likely to be transferred (pandemic, 341 [11.8%] vs historical, 323 [8.7%]) and have a history of congestive heart failure (pandemic, 3334 [23.3%] vs historical, 3654 [20.6%]; P < .001), dialysis (pandemic, 1428 [10.5%] vs historical, 1633 [9.7%]; P = .02), or anticoagulation (pandemic, 3459 [24.1%] vs historical, 3825 [21.6%]; P < .001).

Pandemic-period elective LEI volumes fell by 20.3% (before the pandemic, 2442 procedures; during the pandemic, 1945 procedures) to 60.0% (before, 2590; during, 1036) from March to June 2020 (P < .001), while emergency LEIs increased by 18.6% (before, 53; during, 63) in April 2020 (P = .03) and urgent LEI volumes increased by 20.3% (before, 364; during, 452) and 32.4% (before, 392; during, 519) in March and May 2020, respectively (P < .001). Conversely, pandemic-period carotid procedures demonstrated statistically significant decline across elective procedures (April: before, 1071; during, 263; decline, 75.4%; May: before, 1027; during, 556; decline, 45.8%; June: before, 943; during, 732; decline, 22.3%; P < .001) and urgent procedures (March: before, 626; during, 594; decline, 5.1%; April: before, 660; during, 423; decline, 35.9%; May: before, 684; during, 503; decline, 26.5%; June: before, 679; before, 461; decline, 32.1%; P < .001). Aortic procedures declined significantly across elective indications (March: before, 598; during, 463; decline, 22.5%; P = .04; April: before, 596; during, 191; decline, 68.0%; May: before, 666; during, 324; decline, 51.4%; June: before, 561; during, 358; decline, 36.2%; P < .001 for April through June), urgent indications (March: before, 77; during, 65; decline, 17.7%; P = .01; April: before, 81; during, 55; decline, 38.8%; P = .01; May: before, 101; during, 86; decline, 14.9%; June: before, 62; during, 40; decline, 36.1% decline; P < .001 for May and June), and emergency indications (May: before, 63; during, 44; decline, 30.1%; June: before, 63; during, 41; decline, 34.8%; P < .001) (Figure).

Compared with historical volumes, urgent and emergency LEIs increased in March, April, and May 2020 as the COVID-19 pandemic surged in the US. Possible causes for increased urgent and emergency LEIs include COVID-19 infection, which has been associated with thrombotic complications, including lower extremity ischemia. Additionally, delayed care may contribute to urgent or emergency LEIs. In a national survey from the National Center for Health Statistics from April to July 2020, 38.7% to 41.5% of households reported a delay in medical care in the prior month because of COVID-19. In Italy and the Netherlands, a reduction in elective LEIs during the pandemic was associated with patients presenting with higher peripheral artery disease severity and increased rates of major amputations.^4,5 That patients treated during the pandemic in this analysis were more likely to have severe comorbidities and be transferred from another institution may indicate a shift toward treating those in more dire medical states than in the prepandemic period.

While declines in elective procedures were expected, concurrent declines in urgent and emergency aortic and carotid interventions throughout the study period were not expected. Because the pandemic is unlikely to reduce incidence of aortic rupture or symptomatic carotid disease, this is more likely because to reduced access to care. Aortic rupture in particular is a time-sensitive condition with significant prehospital mortality, and the additional burden of COVID-19 may hinder expedient transfer and resuscitation efforts, causing excess deaths. Indeed, national reports have identified that 34% of excess deaths during the pandemic cannot be attributed to COVID-19 alone.⁶

Study limitations include the retrospective observational approach, which prohibits the determination of causality. Variables such as surgical urgency were clinician reported and thus vulnerable to error. Additionally, the COVID-19 status of patients is unknown. Reduced surgical volumes could be confounded by reduced reporting during quarantine, although this would be expected to negatively affect urgent and emergency volumes, where an increase was actually observed for LEIs.

While elective and emergency interventions for aortic and carotid disease decreased throughout the COVID-19 pandemic, nonelective revascularization for acute limb ischemia increased in March to May 2020. Future research should examine potential adverse effects of these trends.

Accepted for Publication: March 14, 2021.

Published Online: April 15, 2021. doi:10.1001/jamasurg.2021.1708

Corresponding Author: Vy Thuy Ho, MD, Division of Vascular Surgery, Department of Surgery, Stanford University School of Medicine, 300 Pasteur Dr, Alway M121, Stanford, CA 94305 (vivianho@stanford.edu).

Author Contributions: Drs Ho and Ross had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Ho, Asch, Leeper, Fukaya, Arya, Ross.

Acquisition, analysis, or interpretation of data: Ho, Eberhard, Asch, Arya, Ross.

Drafting of the manuscript: Ho, Eberhard, Ross.

Critical revision of the manuscript for important intellectual content: Ho, Asch, Leeper, Fukaya, Arya, Ross.

Statistical analysis: Ho, Arya.

Administrative, technical, or material support: Eberhard, Arya.

Supervision: Asch, Leeper, Fukaya, Ross.

Conflict of Interest Disclosures: None reported.

Funding/Support: Dr Ho is supported by the Stanford Intermountain Fellowship in the Department of Primary Care and Population Health at Stanford University. Ms Eberhard is supported by a grant from the Deutsche Herzstiftung e.V. (grant K/37/19). Dr Ross is supported by the National Heart, Lung, and Blood Institute (award 5KO1HL148639-02).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.