The challenge of maintaining necessary vascular and endovascular services at a referral center in Northern Italy during the COVID-19 outbreak.

OBJECTIVES: The Padova Hospital Vascular Surgery Division is located in Veneto, one of the area of the Northern Italy most hit by the Coronavirus disease 2019 outbreak. The aim of this paper is to describe the protocols adopted and to evaluate their impact during the acute phase of Coronavirus spread, focusing on the management of elective and urgent/emergent surgery, outpatients activity, and also health staff preservation from intra-hospital Coronavirus disease 2019 infection. METHODS: Several measures were progressively adopted in the Padova University Hospital to front the Coronavirus disease 2019 outbreak, with a clear strong asset established by 9 March 2020, after the Northern Italy lockdown. Since this date, the Vascular Surgery Unit started a "scaled-down" activity, both for elective surgical procedures and for the outpatient Clinical activities; different protocols were developed for health preservation of staff and patients. We compared a two months period, 30 days before and 30 days after this time point. In particular, emergent vascular surgery was regularly guaranteed as well as urgent surgery (to be performed within 24 h). Elective cases were scheduled for "non-deferrable" pathology. A swab test protocol for COVID-19 was applied to health-care professionals and hospitalized patients. RESULTS: The number of urgent or emergent aortic cases remained stable during the two months period, while the number of Hospital admissions via Emergency Room related to critical limb ischemia decreased after national lockdown by about 20%. Elective vascular surgery was scaled down by 50% starting from 9 March; 35% of scheduled elective cases refused hospitalization during the lockdown period and 20% of those contacted for hospitalization where postponed due to fever, respiratory symptoms, or close contacts with Coronavirus disease 2019 suspected cases. Elective surgery reduction did not negatively influence overall carotid or aortic outcomes, while we reported a higher major limb amputation rate for critical limb ischemia (about 10%, compared to 4% for the standard practice period). We found that 4 out of 98 (4%) health-care providers on the floor had an asymptomatic positive swab test. Among 22 vascular doctors, 3 had a confirmed Coronavirus disease 2019 infection (asymptomatic); a total of 72 swab were performed (mean = 3.4 swab/person/month) during this period; no cases of severe Coronavirus disease 2019 (deaths or requiring intensive care treatment) infection were reported within this period for the staff or hospitalized patients. CONCLUSIONS: Elective vascular surgery needs to be guaranteed as possible during Coronavirus disease 2019 outbreak. The number of truly emergent cases did not reduce, on the other side, Emergency Room accesses for non-emergent cases decreased. Our preliminary results seem to describe a scenario where, if the curve of the outbreak in the regional population is flattened, in association with appropriate hospitals containment rules, it may be possible to continue the activity of the Vascular Surgery Units and guarantee the minimal standard of care.

[The future of vascular medicine]. / Die Zukunft der Gefäßmedizin.

In the future vascular medicine will still have a great impact on health of people. It should be noted that the aging of the population does not lead to a dramatic increase in patient numbers, but will be associated with a changing spectrum of co-morbidities. In addition, vascular medical research has to include the intensive care special features of vascular patients, the involvement of vascular medicine in a holistic concept of fast-track surgery, a geriatric-oriented intensive monitoring and early geriatric rehabilitation. For the future acceptance of vascular medicine as a separate subject area under delimitation of cardiology and radiology is important. On the other hand, the subject is so complex and will become more complex in future specialisations that mixing of surgery and angiology is desirable, with the aim to preserve the vascular surgical knowledge and skills on par with the medical and interventional measures and further develop them. Only large, interdisciplinary guided vascular centres will be able to provide timely diagnosis and therapy, to deal with the growing multi-morbidity of the patient, to perform complex therapies even in an acute emergency and due to sufficient number of cases to present with well-trained and experienced teams. These requirements are mandatory to decrease patients' mortality step by step.

Changes in red blood cell transfusion practice during the turn of the millennium: a retrospective analysis of adult patients undergoing elective open abdominal aortic aneurysm repair using the Mayo database.

BACKGROUND: Significant changes in perioperative red blood cell (RBC) transfusion practice during the past two decades have been reported but similar data are not available for patients undergoing abdominal aortic aneurysm (AAA) surgery. METHODS: Adult patients who had undergone primary, elective, open AAA repair were stratified into one of two transfusion-related groups: early practice (1980-1982) or late practice (2003-2006). RBC transfusion and hemoglobin concentration (Hb) were analyzed as a continuous variable and compared between groups with use of the rank sum test. Perioperative complications were compared between groups with Fisher's exact test. Data were age adjusted, and analyses were corrected for multiple comparisons. RESULTS: Compared with the early practice group, patients in the late practice group had significantly lower intraoperative (mean 10 +/- 1.4 vs. 11.5 +/- 1.5 g/dL), postoperative (11.9 +/- 1.4 vs. 13.4 +/- 1.5 g/dL), and discharge Hbs (mean 10.8 +/- 1.2 vs. 12.5 +/- 1.5 g/dL) (p < 0.0001 for each variable). Patients in the late practice group were significantly less likely to receive intraoperative allogenic transfusions (46% vs. 99%, p < 0.0001). Additionally, significantly fewer total allogenic units of RBCs per patient were transfused in the late practice group (mean 1.7 vs. 4.3, p < 0.0001). Intraoperative autotransfusions were used in 97% of the late practice patients but in none of the early practice patients (p < 0.0001). In the late practice group, 119 patients (40%) experienced a major perioperative morbidity or mortality event compared with 106 patients (35%) in the early practice group (p = 0.27). CONCLUSION: In this retrospective analysis, we observed significantly lower perioperative Hb, fewer allogenic RBC transfusions, and more autotransfusions in open AAA repairs done in 2003-2006 versus those done in 1980-1982. Additionally, late transfusion practice patients were older and had more comorbid diseases. Despite these observations, no significant differences in perioperative morbidity or mortality were observed between groups.

Specialisation within vascular surgery.

Despite its short existence, vascular surgery has already grown out of the scope of a mono-specialty. Meanwhile emerging interests of other competing specialties push into the field of vascular care. Continuous technological innovation drives the need for sub-specialisation to provide disease-centred expertise; however, treatment success equally depends on balanced patient-centred care. Vascular surgeons are amidst this controversy and are currently challenged by their own demand to offer all aspects of vascular care - as "the vascular specialist". This article discusses the natural driving forces towards sub-specialisation and appraises advantages and limitations with respect to the future of integrated vascular care.

Challenging traditional beliefs: microsurgery for arteriovenous malformations of the basal ganglia and thalamus.

OBJECTIVE: Arteriovenous malformations of the basal ganglia and thalamus are often managed with radiosurgery or observation, without consideration of microsurgery. Given the devastating effects of hemorrhage from these lesions, the accumulating evidence that they bleed more frequently than their lobar counterparts should prompt more creative thinking regarding their management. METHODS: A review of the endovascular, microsurgical, and radiosurgical literature for arteriovenous malformations of the basal ganglia and thalamus was performed, with close attention to surgical approaches, obliteration rates, and procedure-related complications. RESULTS: A complete resection rate of 91% and a mortality rate of 2.4% were found across surgical series of these lesions. These contrast with a 69% rate of complete obliteration and a 5.3% mortality rate (from latency-period hemorrhage) found when compiling results across the radiosurgical literature. CONCLUSION: Given an appropriate surgical corridor of access, often afforded by incident hemorrhage, arteriovenous malformations of the basal ganglia and thalamus should be considered for microsurgical extirpation with preoperative embolization. In experienced hands, this approach presents an expeditious and definitive opportunity to eliminate the risk of subsequent hemorrhage and resultant morbidity and mortality.

The endovascular operating room as an extension of the intensive care unit: changing strategies in the management of neurovascular disease.

Technological advances within the field of endovascular neurosurgery have influenced the management of the neurovascular patient within the intensive care unit (ICU). The endovascular operating room has, in fact, become an extension of the ICU in certain cases. Given the rapid development of new endovascular technologies, it is more important than ever for neurosurgeons to remain intimately involved with the care of their patients within the ICU. This article offers an overview of the evolution in ICU management of neurovascular disease and provides a framework for the incorporation of the endovascular operating room in the intensive care management of patients with this disease.

Newer developments of extra-anatomic bypass.

We have analyzed our eight year experience with more than 200 instances of extra-anatomic bypass and have made certain observations. Extra-anatomic bypass provides an acceptable alternative to extensive direct intra-abdominal and intrathoracic vascular reconstructive procedures. This is particularly true in high risk patients and in the presence of infection. While axillobifemoral bypass is widely known and used, other types of extra-anatomic bypass are emphasized. These are axillary-axillary, axillopopliteal, axillotibial and axillofemoral bypass under local anesthesia. Technical factors, such as the type of graft, the course of the bypass and ancillary techniques to improve the long term patency, are also discussed herein.