The vascular surgical unit in Belfast serves a population of 1.8million people. The Covid pandemic brought a restriction in access to primary care services, reduction in availability of face to face vascular clinics and less operating theatre access. This retrospective review sought to establish if there has been an increase in the number of major limb amputations as a consequence of the pandemic and if so, seek to clarify the reasons.

Data from a prospectively maintained theatre database (TMS) was reviewed from the dates of the first lockdown until the first easing of restrictions. All major limb amputations and surgical bypass procedures were identified and patient demographics obtained from their Northern Ireland Electronic Care Records. Note was also made if the patient had previously been known to the vascular service, any previous limb salvage interventions including major limb amputation, and the mode of referral for the current episode. Comparisons were drawn against the corresponding number of days prior to the start of the pandemic.

Between 28th March 2020 and 23rd April 2021 (391 days), 170 patients underwent a total of 198 major limb amputations, an increase of over 50% in comparison to the 391 days prior to the pandemic. 134 patients were male, average age 70 with a breakdown of 116 transtibial amputations, 79 transfemoral amputations and 3 through knee amputations. Of these patients, 128 were deemed to be admitted on an emergency basis with 31 being admitted via the diabetic foot service. None of the patients who underwent amputation were on a waiting list for revascularisation prior to the pandemic. 93 of the 128 emergency admissions proceeded to major limb amputation during the same admission with revascularisation attempts for 35. Reasons for proceeding to amputation were diabetic foot or heel sepsis (15), non-healing amputations (3), non-salveagable (23), non-reconstructible disease (18), unfit for revascularisation (24), patient choice: declining revascularisation (5), non-diabetic heel necrosis (2) and trauma, phlegmasia, lymphoedema and infected bypass (all 1 each). 193 surgical lower limb salvage procedures were carried out in the same timeframe whereas only 153 were performed pre-pandemic, demonstrating a 26% increase. None of the patients had been waiting for an urgent outpatient vascular review, either being referred directly from A&E, the regional diabetic foot clinic or another medical or surgical specialty.

This data provides further evidence that the Covid-19 pandemic has caused significant problems in access to primary healthcare services such as GP appointments, podiatry review and district nursing. Whilst operating lists have been cut due to redeployment of staff, our output in terms of surgical revascularisation has increased. Unfortunately this has not been enough , evidenced by the high volume of major limb amputations. More resources are needed to improve timely access, review, imaging and intervention at both primary care and tertiary level for vascular patients or the Covid-19 effect will be apparent for years to come.