March 26, 2021
Operations on the aorta, the elimination of aneurysms, the restoration of blood flow to the body or leg arteries or the amputation of extremities that have been damaged by severe circulatory disorders – all of these are surgical interventions that are particularly risky during the Covid-19 pandemic are connected. Because a SARS-CoV-2 infection is fatal in acute vascular surgery treated patients in a striking number of cases, according to a result of the international COVER study on the care of vascular patients during the pandemic.
Due to the increased risk of severe Covid-19 courses, the German Society for Vascular Surgery and Vascular Medicine eV (DGG) recommends vaccinating patients against the SARS-CoV-2 virus in advance of planned vascular surgery and thus adjusting the vaccination priorities.
Early on in the course of the Covid-19 pandemic, it became clear that the SARS-CoV-2 virus not only affects the respiratory tract, but also severely affects the blood vessel system. “It is now known that the blood vessel walls can become inflamed in the course of a SARS-CoV-2 infection and that the tendency for blood to clot is significantly increased,” says DGG expert Professor Dr. med. Thomas Schmitz-Rixen, Director of the Clinic for Vascular and Endovascular Surgery at the University Hospital Frankfurt am Main. For patients who already suffer from vascular diseases, a SARS-CoV-2 infection therefore carries a particular risk; they are particularly often affected by severe or even fatal courses of Covid-19.
As the data collected so far as part of the COVER study (COvid-19 Vascular sERvice) show, this also applies in particular to patients after vascular surgery such as the operation of an aortic aneurysm, the restoration of blood flow in severely atherosclerotic arteries or after amputation of an extremity due to peripheral arterial disease. “Depending on the type of surgical intervention, the mortality in these patients increases to up to 40 percent,” says Schmitz-Rixen (1).
In retrospect, the Italian Lombardy, which was particularly badly affected by the first Covid-19 wave, showed a particularly high mortality rate when vascular surgery and Covid-19 disease coincided. As doctors working there report in the European Journal of Vascular and Endovascular Surgery, a SARS-CoV-2 infection increased the risk of death after a vascular operation fourfold, the rate of serious complications increased threefold (2). “The approval of three vaccines against Covid-19 now gives us the opportunity to prevent this additional risk,” says Schmitz-Rixen. This opportunity should be used whenever possible – for example, by giving the affected patients preferential vaccination and thus giving them higher priority if necessary.
In contrast to emergencies, most vascular operations that can be planned can be postponed by a few weeks in order to gain time for a vaccination. “Whether such a delay is possible without risk must be decided on a case-by-case basis,” emphasizes Professor Dr. med. Markus Steinbauer, head physician at the Clinic for Vascular Surgery at the Barmherzige Brüder Hospital in Regensburg and President of the DGG 2021. For example, the treatment of symptomatic or ruptured aneurysms as well as limbs that are critically insufficiently supplied with blood or are threatened by sepsis cannot be postponed. In the case of severe narrowing of the carotid arteries or large, but symptom-free aortic aneurysms, postponement should be carefully examined.
This is also shown by the data from the COVER study: If vascular surgery is delayed too long, mortality also increases significantly during the acute postoperative phase (3). As the evaluation of the operation results from 57 clinics in 19 countries showed, this was the case during the first lockdown, when work was often carried out in emergency mode and many operations that were not classified as emergency were canceled.