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canceled or postponed in 2020 [3]. In order to stratify the urgency of procedures and surgical care, tier classifications were designed to focus on preserving scarce resources and human capital, maintaining optimal patient outcomes, reducing exposure risk, and upholding the necessary public health measures of physical distancing Vascular surgery procedures can require a significant amount of equipment and resource allocation, not only in the operating suite but postoperatively in critical care units—a particularly scarce resource during the COVID-19 PHE. Therefore, there was early recognition of the need to limit operative capacity to only emergent and/or urgent procedures. In some geographic regions affected disproportionately worse, for example, Michigan, guidelines were developed by independent health systems that were ultimately shared with national programs [8]. Rapidly, however, guidelines were set forth by national surgical and specialty societies, such as the American College of Surgeons (ACS) and the Society for Vascular Surgery to triage vascular surgical care during the time of resource scarcity These tier systems created a graduated hierarchy of treatment urgency in which life- and limb-threatening procedures take precedence for intervention and were assigned a high priority; this served as an effective method to decrease vascular surgical volumes during the pandemic with minimal increase in patient morbidity. Attaching this system to surgical activity condition (SURGCON) and vascular activity condition (VASCCON) frameworks has been suggested to provide more granular specialty-specific and relevant clinical guidance for vascular surgery triage, although the combination has not yet been validated Mouawad et al conducted a cross-sectional survey of more than 530 practicing vascular surgeons in the United States during the height of the pandemic. The overwhelming majority of respondents (>91%) noted elective surgery cancellations, despite no regional variation in the presence of COVID-19 operating room protocols, availability of personal protective equipment (PPE), and adherence to national surgical standards In the in-hospital setting, only 8.3% of respondents were still performing elective cases, focused primarily on dialysis access, followed by aortic repair and lower extremity revascularization Outpatient vascular surgical care was affected, with most vascular surgeons reporting disruption to their outpatient laboratory/ambulatory center schedules—in this setting, most were performing urgent procedures focused only on advanced peripheral arterial disease and dialysis access. Not surprisingly, prioritization of life over limb was clearly demonstrated, with the majority of elective cases focused on aortic repair and maintenance of dialysis function rather than peripheral arterial disease or venous procedures. The most common redeployment was to the intensive care unit, and central line teams were formed to minimize multiprovider exposure and leverage the expertise of vascular surgeons; in all, 34% of vascular surgeons were redeployed to new roles Geographic variation was identified with redeployment highest in areas most affected by the pandemic. Globally, however, 5.5% of senior surgeons were redeployed to support other specialties, compared with 53.5% of junior vascular surgical staff Vascular surgical services and access to care have been severely challenged due to the pandemic. There have been profound changes in the way vascular care is delivered The Vascular and Endovascular Research Network (VERN) is an established vascular research collaborative that responded rapidly to the pandemic by delivering the COVER (COVID-19 Vascular Service) study, an international prospective mixed methodology project Findings noted significant changes to peripheral arterial disease practice, in which the majority of units offered major amputation or palliation rather than attempting revascularization for chronic limb-threatening ischemia, and 60.4% of groups promoted an endovascular-first treatment strategy particularly in critical limbs Furthermore, thresholds for intervention on abdominal aortic aneurysms were raised and 45.8% of facilities halted aortic screening
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