Is There Any Fun in a Puzzle When All Pieces Look the Same?

To date, a total of 328 466 research and education articles on COVID-19 can be found via the National Library of Medicine (PubMed.gov). For almost three years, researchers have sought to determine the possible collateral damage caused either directly or indirectly by this devastating pandemic. However, despite enormous efforts to take advantage of large clinical and administrative registries, the data on patients with peripheral vascular disease remain sparse. While the heart and brain were frequently in the spotlight of public interest, it was expected that our central target population would suffer from delayed processes, staff shortages, low adherence to vaccination, and other factors directly related to the virus. Needless to say, any crisis will always hit marginalised groups of low socio-economic status first.

When discussing large registries, there is no way to avoid the commendable efforts of the UK National Vascular Registry over the past few years. In the current study, Birmpili et al. have used valuable data on almost 37 000 procedures, 7 245 of which were lower extremity major amputations and 29 693 of which were peripheral revascularisations, while < 5% had SARS-CoV-2 infection.¹

Based on these data, the authors concluded that, during the pandemic, there was excess post-operative mortality in patients undergoing lower limb vascular procedures, which was associated with SARS-CoV-2 infections.¹

Is this finally the missing piece in the puzzle? Or do we have to accept that all pieces in a puzzle ultimately look different? The inherent differences between global healthcare systems have been controversially discussed by the vascular community, and the situation in UK certainly has some interesting peculiarities.² The treatment reality on the other side of the North Sea may be different. While the number of centres performing aneurysm surgery in the UK decreased from 132 in 2012 to 64 in 2022,² this number is currently more than 500 in Germany. In 2018, almost 670 centres performed approximately 300 000 peripheral arterial revascularisations, another signature of the German healthcare system.³ Interestingly, in a recent population based analysis of health insurance claims data from this very decentralised setting, it was also found that in hospital mortality increased during the COVID-19 pandemic compared with the previous three years for patients with acute stroke but not for other vascular emergencies such as aortic rupture and acute limb ischaemia.⁴ Hence, it appears that this big Central European system with approximately 1 600 general hospitals and eight hospital beds per 1 000 inhabitants (only two beds in UK) worked rather well during the first waves of the pandemic. However, there is a striking paucity of robust data on the outpatient care situation, as well as on the social networks and welfare of patients with vascular disease during the subsequent waves of this health catastrophe. Moreover, the very complex interactions (e.g., transferrals) between the many centres are seldom covered by single centre or multicentre observational data.

Will we ever have an answer to the question of whether and to what extent patients were disadvantaged by collateral damage during the pandemic? The interesting study by Birmpili et al. has shed light on this highly complex issue using robust and comprehensive data from a renowned vascular registry. How we interpret these findings, however, and if we need to adapt practices as a result need to be discussed.

Lastly, while thousands of research articles have addressed the collateral damage of the COVID-19 pandemic, we must not forget that people in Ukraine are still suffering from different collateral damage. While we still do not have the power to stem COVID-19, it seems obviously easy to end this offensive war.⁵