treatments. [1] [2] [3] [4] In United Kingdom (UK), like the rest of the world, all elective cardiac and aortovascular 156 surgery were put on hold in order to protect patients access to emergency and urgent surgery. 157
Patients with acute aortic syndrome, having a devastating natural history with incremental 158 hourly risk of mortality, require emergency surgery. [5] 159
In this study, we assess the incidence, access to emergency treatment, logistical issues as well 160 A total of 9 patients were not managed surgically due to a variety of reasons. 281
Three patients were accepted for emergency surgery but died either waiting for transfer or en 282 route to the specialised centre or during the anaesthetic induction due to aortic rupture and 283 cardiac tamponade. Mean age was 63.3 years (range 45 -81 years) 284
Five patients were denied emergency surgery due to clinical complexity. Three of them had 285 history of previous cardiac or aortic surgery and one of them had signs of COVID-19 on the 286 preoperative CT scan. Mean EuroScore II was 16.9%. Two patients were discharged alive, 287 hence the mortality for this group was 60%. not require surgical treatment. He was diagnosed of COVID-19 during the hospital admission 290 but did not develop any symptoms or respiratory complications and was discharged home. 291
Regional and temporal variation in presentation of acute aortic syndromes 293
There was a clear regional variation in the presentation of the AAS (Table 3) partipating aortic centres to assess access to emergency treatment for AAS patients during the 460 early months of the COVID-19 pandemic in the UK. A total of 88 patients were analysed and 461 90% of them underwent surgery, with similar outcomes to pre-pandemic times. Despute the 462 COVID-19 screening was not awaited before emergency surgery was offered, only 7 patients 463 of COVID-19 cases started to increase exponentially and the AAS activity decreased initially 472 due to the reduced presentation to emergency departments. Both curves reached a peak 473 around mid of April to descend in a parallel way after that. Note that he scale for the COVID-474 19 mortality has been adapted and has to be multiplied x100. 