Is there a vascular side of the story? Vascular consequences during COVID-19 outbreak in Lombardy, Italy

Unexpected arterial thrombosis and acute limb ischemia in a young male patient with COVID-19: A case report

Introduction

The spread of severe acute respiratory syndrome coronavirus 2 has resulted in coronavirus disease 2019 (COVID-19) pandemic, raising significant concerns. COVID-19 can lead to thrombotic complications such as acute limb ischemia (ALI). In patients with COVID-19, thrombotic complications may increase the risk of morbidity and mortality.

Presentation of case

We report the case of a 37-year-old man who presented with a 2 weeks history of right foot pain, toes blackish discoloration, and numbness. He tested positive for COVID-19 10 days prior to his presentation. Computed tomography angiography (CTA) of the lower limbs revealed near-complete occlusion of the right popliteal artery with single-vessel posterior tibial artery runoff. The patient was brought to a hybrid operating room, and diagnostic angiography confirmed the diagnosis. He underwent popliteal artery thromboembolectomy and intraoperative thrombolysis through a posterior approach. A completion angiography demonstrated a patent popliteal artery with a 2-vessels patency to the foot. His postoperative recovery was uneventful. After surgery, the popliteal, anterior tibial, and posterior tibial arteries were all palpable. The patient was discharged home on antiplatelet therapy with frequent postoperative follow-ups during the last 1 year in our outpatient clinic.

Discussion

The frequency of ALI has reduced worldwide, and the hypercoagulable condition remains an infrequent cause of limb ischemia. Patients with COVID-19 have a 35%-45% thromboembolic complication rate. In many studies, the virus launches a second attack between 7 and 14 days after symptom onset, possibly causing hypercoagulability. If conservative treatment fails, various surgical methods, including thromboembolectomy, thrombolysis, and thrombosuction, can be performed to treat ALI.

Conclusion

In mild ALI symptoms, unfractionated heparin can be used with vigilant follow-up. Open and endovascular procedures are currently used to treat patients with acute limb ischemia, and technological advancements continue to make interventions easier and safer.

Acute Limb Ischemia among COVID-19 Patients in Hospital Kuala Lumpur

BACKGROUND: Acute arterial thromboembolism among the novel coronavirus 2019 (COVID-19) patients is worrying as it can result in significant thrombotic events. AIM: The research aimed to determine the clinical results of COVID-19 infected patients who had ALI (acute limb ischaemia) during the COVID-19 epidemic. METHODS: ALI patients who had a positive COVID-19 were included in the observational cohort study, which was conducted at a single centre. The primary outcomes were 30 days mortality, limb salvage, and successful revascularization. RESULTS: From May to October 2021, data from 21 ALI subjects who had positive COVID-19 were analysed. Of the 21 included subjects, 10 were males (48%). Their mean age was 65±5 years. In nine subjects (42%), revascularization was done. Four (19%) of the 21 persons died while they were hospitalized. Twelve patients underwent major amputation and among them, one patient died after a month of hospitalization for COVID-19-related pneumonia.  Among the 12 patients that underwent amputation, 10 of them presented with ALI during the first week of COVID-19 illness. Only one patient developed acute limb ischaemia despite being on heparin thromboprophylaxis. CONCLUSION: Despite attempts at revascularization, ALI-associated with COVID-19 has high mortality and high rates of limb loss. In our experience, major amputation is required in up to a third of patients. This poor result appears to confirm that these infected individuals have a marked hypercoagulable condition. However, adhering to the treatment protocol of heparin thromboprophylaxis confers a benefit in this patient group.

Impact of COVID-19 on vascular patients worldwide: analysis of the COVIDSurg data

BACKGROUND

The COVIDSurg collaborative was an international multicenter prospective analysis of perioperative data from 235 hospitals in 24 countries. It found that perioperative COVID-19 infection was associated with a mortality rate of 24%. At the same time, the COVER study demonstrated similarly high perioperative mortality rates in vascular surgical patients undergoing vascular interventions even without COVID-19, likely associated with the high burden of comorbidity associated with vascular patients. This is a vascular subgroup analysis of the COVIDSurg cohort.

METHODS

All patients with a suspected or confirmed diagnosis of COVID-19 in the 7 days prior to, or in the 30 days following a vascular procedure were included. The primary outcome was 30-day mortality. Secondary outcomes were pulmonary complications (adult respiratory distress syndrome, pulmonary embolism, pneumonia and respiratory failure). Logistic regression was undertaken for dichotomous outcomes.

RESULTS

Overall, 602 patients were included in this subgroup analysis, of which 88.4% were emergencies. The most common operations performed were for vascular-related dialysis access procedures (20.1%, N.=121). The combined 30-day mortality rate was 27.2%. Composite secondary pulmonary outcomes occurred in half of the vascular patients (N.=275, 45.7%).

CONCLUSIONS

Mortality following vascular surgery in COVID positive patients was significantly higher than levels reported pre-pandemic, and similar to that seen in other specialties in the COVIDSurg cohort. Initiatives and surgical pathways that ensure vascular patients are protected from exposure to COVID-19 in the peri-operative period are vital to protect against excess mortality.

Acute limb ischemia among patients with COVID-19 infection

OBJECTIVE/BACKGROUND

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has been associated with thrombotic complications such as deep vein thrombosis or stroke. Recently, numerous cases of acute limb ischemia (ALI) have been reported although pooled data are lacking.

METHODS

We systematically searched PubMed, Embase, Scopus, and the Cochrane Library for studies published online up to January 2021 that reported cases with SARS-CoV-2 infection and ALI. Eligible studies should have reported early outcomes including mortality. Primary endpoints included also pooled amputation, clinical improvement, and reoperation rates.

RESULTS

In total, 34 studies (19 case reports and 15 case series/cohort studies) including a total of 540 patients (199 patients were eligible for analysis) were evaluated. All studies were published in 2020. Mean age of patients was 61.6 years (range, 39-84 years; data from 32 studies) and 78.4% of patients were of male gender (data from 32 studies). There was a low incidence of comorbidities: arterial hypertension, 49% (29 studies); diabetes mellitus, 29.6% (29 studies); dyslipidemia, 20.5% (27 studies); chronic obstructive pulmonary disease, 8.5% (26 studies); coronary disease, 8.3% (26 studies); and chronic renal disease, 7.6% (28 studies). Medical treatment was selected as first-line treatment for 41.8% of cases. Pooled mortality rate among 34 studies reached 31.4% (95% confidence interval [CI], 25.4%%-37.7%). Pooled amputation rate among 34 studies reached 23.2% (95% CI, 17.3%-29.7%). Pooled clinical improvement rate among 28 studies reached 66.6% (95% CI, 55.4%%-76.9%). Pooled reoperation rate among 29 studies reached 10.5% (95% CI, 5.7%%-16.7%). Medical treatment was associated with a higher death risk compared with any intervention (odds ratio, 4.04; 95% CI, 1.075-15.197; P = .045) although amputation risk was not different between the two strategies (odds ratio, 0.977; 95% CI, 0.070-13.600; P = .986) (data from 31 studies).

CONCLUSIONS

SARS-CoV-2 infection is associated with a high risk for thrombotic complications, including ALI. COVID-associated ALI presents in patients with a low incidence of comorbidities, and it is associated with a high mortality and amputation risk. Conservative treatment seems to have a higher mortality risk compared with any intervention, although amputation risk is similar.

COVID-19 and supra-aortic trunks disease: review of literature about critical phase and sequelae

The acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is responsible for the COVID-19 disease, a global pandemic. A strong association has been documented between COVID-19 and cardiovascular events, although the exact pathophysiological mechanism is still unclear. Carotid atherothrombosis and ischemic stroke represents one of the possible severe manifestations of COVID-19, as a leading cause of long-term disability and death. Different complex intertwined mechanisms seem to underlie the endothelitis which is the cause of multiple cardiovascular manifestations. To date, few case series describing COVID-19 and acute ischemic stroke caused by cervical carotid thrombosis have been published. All the patients shared common similar radiographic features, comorbidities, and biomarker profiles. The aim of this brief review is to analyze the impact of COVID-19 pandemic in the management of a Vascular Surgery Department, changing the daily vascular practice, as well as to provide practical suggestions for symptomatic carotid stenosis, while reviewing published literature.

COVID-19 and acute limb ischemia: a systematic review

INTRODUCTION

The main goal of this systematic review is to analyze the outcomes of acute limb ischemia (ALI) in patients suffering from the novel Coronavirus COVID-19 (Sars-Cov-2).

EVIDENCE OF ACQUISITION

A systematic review on MEDLINE and Embase was conducted up to May 15, 2021. All papers were sorted by abstract and full text by two independent authors. Systematic reviews, commentaries, and studies that did not distinguish status of COVID-19 infection were excluded from review. Patient demographics were recorded along with modality of treatment (endovascular and/or surgical). We analyzed 30-day outcomes, including mortality. Primary outcome was to evaluate clinical characteristic of ALI in patients affected by SARS-CoV-2 in term of location of ischemia, treatment options and 30-day outcomes.

EVINDENCE SYNTHESIS

We selected 36 articles with a total of 194 patients. The majority of patients were male (80%) with a median age of 60 years old. The treatment most used was thromboembolectomy (31% of all surgical interventions). A total of 32 patients (19%) were not submitted to revascularization due to critical status. The rate of technical success was low (68%) and mortality rate was high (35%).

CONCLUSIONS

This review confirms that Sars-Cov-2 is associated with a high risk of ALI. Further studies are needed to investigate the association and elucidate potential mechanisms, which may include a hypercoagulable state and hyperactivation of the immune response. Furthermore, management of ALI is not standardized and depends on patient's condition and extension of the thrombosed segment. ALI in COVID-19 patients is associated with high risk of failure of revascularization and perioperative mortality.

COVID-19 and aortic disease: a practical systematic review of the literature on management and outcomes

Since the advent of the 2019 coronavirus (COVID-19) outbreak, vascular specialists have faced dramatic changes in clinical and surgical practice. Although COVID-19 pulmonary signs and symptoms were the most pertinent problems initially, in the long term cardiovascular complications became the most fearsome, with poor outcomes in terms of morbidity and mortality. Algorithms and decision-making procedures have been modified, not only to treat new clinical findings in COVID-19 positive patients, but also to avoid complications related to pulmonary and systemic infections. Additionally, COVID-19 negative patients experienced challenging management, due to hospital crowding, the risk of nosocomial COVID-19 transmission, and pandemic emergencies. In this context, aortic interventions were subject to several difficulties. First, in COVID-19 positive patients, there was the onset of new pathological scenarios including thrombotic manifestations and the subsequent complications. Second, in both COVID-19 negative and positive patients, there was a need to deliver optimal treatment with acceptable perioperative risks, forcing a rethinking of decisionmaking especially in terms of indications for treatments. The aim of this systematic review is to present evidence published on COVID-19 and aortic-related issues, highlighting some challenging aspects regarding management, treatment and outcomes.

Impact of COVID-19 on aortic operations

The coronavirus disease 2019 (COVID-19) outbreak has profoundly affected all aspects of medicine and surgery. Vascular surgery practice and interventions were also forced to change in order to deal with new COVID-19-related priorities and emergencies. In this setting, difficulties in aortic disease management were two-fold: new vascular complications related to COVID-19 infection and the need to guarantee prompt and correct treatment for the general "non-COVID-19" population. Furthermore, discomfort deriving from precautions to minimize the risk of virus transmission among patients and among health care professionals, the need to separate COVID-19-positive from COVID-19-negative patients, and the high incidence of postoperative complications in COVID-19 cases created a challenging scenario for cardiac operations. The aim of this review was to provide evidence derived from the published literature (case reports, case series, multicenter experience, and expert opinion) on the impact of the COVID-19 outbreak on aortic vascular surgery services and interventions, describing COVID-19-related findings, intraoperative and postoperative outcomes, as well as the impact of the COVID-19 outbreak on noninfectious aortic patients.