The Impact of the COVID-19 Public Health Crisis on the Surgical Management of Abdominal Aortic Aneurysm Rupture

Objectives: The COVID-19 epidemic introduced significant systems- and disease-based uncertainty into Abdominal Aortic Aneurysm (AAA) rupture management. The goal of this work was to evaluate whether short-term AAA rupture outcomes during COVID-19 were comparable to pre-COVID era outcomes and to explore the impact of COVID status and COVID era healthcare systems restrictions on AAA rupture outcomes.

Methods: The Vascular Quality Initiative (VQI) database was queried for all ruptured AAAs that underwent intervention from January 1^st, 2019 to August 31^st, 2022. Patients were divided into pre-COVID (1/1/19-12/31/19) and COVID (4/1/20-8/31/22) cohorts. The COVID group was subdivided into COVID unknown, COVID-, and COVID+ subgroups. 1/1-3/31/2020 was excluded due to COVID status uncertainty during this time. For the univariate analysis, categorical variables were compared using the Χ² test; continuous variables were compared either using a two-tailed heteroscedastic Student's T-test or ANOVA. The multivariate analysis was performed using logistic regression module of IBM SPSS Statistics V25.

Results: 2,145 cases (pre-COVID: 745; COVID: 1,400) of AAA rupture were collected. Only 4 documented cases of rupture repair occurred during April 2020 compared to pre-COVID average of 62.1 cases/month (Figure 1). Rupture case numbers recovered to pre-COVID volumes by September 2020. COVID+ patients were less likely to be transferred from outside institutions and experienced delays to OR arrival (time of symptom start to incision of 43.3 hours for COVID+ vs 24.4 hours for all COVID era). Although the COVID+ mortality rate for AAA rupture was higher the overall COVID era mortality rate (31.4% vs. 24.9%) in the univariate analysis, this mortality difference went away with comorbid adjustments. However, COVID+ patients were more likely to have untreated COPD, require post-op ventilatory & vasopressor support, and undergo amputation rather than salvage for acute leg ischemia (Table 1). No statistically significant differences between pre-COVID and COVID cohorts were observed with gender, race, age, smoking, cardiac history or perioperative events, dialysis or pre-op creatinine, prior aneurysm repair, intervention choice of open vs EVAR, maximum AAA diameter, or post-operative length of stay.

Conclusions: The COVID-19 epidemic introduced numerous structural changes in healthcare, creating delays and obstacles to patients' abilities to receive pre-hospital and hospital care. Despite these systems-level obstacles with a highly morbid disease process, COVID era patients were not at an increased risk for mortality regardless of COVID status and were largely comparable to pre-COVID era patients.