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Indriani S, Amshar M, Nugraha RA, Siddiq T, Adiarto S. Acute Limb Ischemia in COVID-19: A Systematic Review. Int J Angiol 2023; 32:215-226. [PMID: 37927841 PMCID: PMC10624540 DOI: 10.1055/s-0043-1771250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2023] Open
Abstract
Numerous studies have reported cases of acute limb ischemia (ALI) in coronavirus disease 2019 (COVID-19), along with a sharp increase of ALI incidence during the COVID-19 pandemic. The objective of this study was to analyze the clinical features, treatment strategies, and outcomes in COVID-19 patients who developed ALI. A systematic search was performed in PubMed, ScienceDirect, and Cochrane to identify relevant articles. Variables of interest included ALI location, ALI and COVID-19 severity, concomitant thrombosis, comorbidities/risk factors, coagulation and inflammatory parameters, therapy, outcome, and cause of death. Data extraction and pooling were conducted by two reviewers. Fifty-six articles with a total of 191 subjects were included in the analysis; 78.5% of the subjects were male; mean age was 64.2 years; 94.2% of cases were ALI de novo; 41.1% of the subjects had ALI stage IIB; 82.7% of ALI occurred in the lower limb. The popliteal artery was the most commonly affected artery (48.2% of subjects); 38.1% of the subjects had severe COVID-19; 11.1% had asymptomatic COVID-19, and 15.9% were post-COVID-19; 50.7% of the subjects had hypertension; 12.0% of the subjects had concomitant thrombosis; 98.1% of the subjects had elevated D-dimer, and 83.3% of the subjects had elevated C-reactive protein; 61.9% of the subjects underwent surgical thromboembolectomy, 21.3% underwent conservative treatment, and 8.1% underwent amputation initially. The overall mortality rate and limb amputation rate were 39.3 and 22.4%, respectively; 67.6% of deaths were due to respiratory failure. Our study supports that COVID-19 is associated with hypercoagulability that may trigger the development of ALI, and that ALI is a possible predictor of poor outcome in COVID-19 patients.
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Affiliation(s)
- Suci Indriani
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
- Division of Vascular Medicine, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Mohamed Amshar
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Raka Aldy Nugraha
- Department of General Medicine, Universitas Indonesia Hospital, Depok, West Java, Indonesia
| | - Taofan Siddiq
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
- Division of Vascular Medicine, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
| | - Suko Adiarto
- Department of Cardiology and Vascular Medicine, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
- Division of Vascular Medicine, National Cardiovascular Center Harapan Kita, Jakarta, Indonesia
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Malkoc A, GnanaDev R, Botea L, Jeney A, Glover K, Retamozo M, GnanaDev D, Schwartz S. A Comparative Analysis of Critical Limb Ischemia in the Intensive Care Unit since the COVID-19 Pandemic. Ann Vasc Surg 2023; 90:39-47. [PMID: 36481674 DOI: 10.1016/j.avsg.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 10/12/2022] [Accepted: 11/04/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Emerging data and case reports have found coagulation abnormalities and thrombosis as sequelae of infection with SARS-CoV-2 (COVID-19). Case reports have reported thrombotic complications caused by COVID-19-related coagulopathy leading to limb loss. Alarmingly, many of these patients had no underlying vascular disease prior to being infected with COVID-19. Many of these case reports discuss patients developing gangrene in the intensive care unit (ICU). Our study compares the incidence of gangrene in the ICU in COVID-19 patients to baseline inpatient levels prior to the pandemic. METHODS This retrospective analysis investigates two subsets of patients from a single institution. The first was from 2020 during the COVID-19 pandemic; the second subset was from 2019 before the pandemic. Demographic data and medication history were ascertained for both groups. Primary outcomes measures included extremity gangrene that developed in the ICU, mortality, and major amputation. RESULTS There were 249 COVID-19 positive patients admitted to the ICU in 2020. In 2019, 1,846 admissions to the ICU took place, of which 249 patients were randomized to chart review. There were 13 cases of gangrene that developed in the ICU, 12 of which took place in 2020. In-hospital mortality was 11.6% in nonCOVID-19 patients in 2019 vs. 41.4% in 2021 (P < 0.001). Only 16.7% of the COVID-19 gangrene patients had previously known arterial disease. Also, patients in the COVID-19 group with gangrene were four times more likely to be smokers (P = 0.004). When the data were stratified to compare between gangrene development and no gangrene development, the combined total gangrene group had longer hospital stays, higher need for blood transfusions, required major amputations, and revascularization. A multivariate logistic regression from the total study similarly demonstrated that COVID-19 infection is associated with an 18.23 times increased risk of gangrene. CONCLUSIONS COVID-19 has resulted in an incomprehensible societal impact that will linger for years to come. The last 2 years have reinforced that COVID-19 will be a part of our clinical practice indefinitely. This study emphasizes the importance of clinician awareness of COVID-19 induced critical limb ischemia in those without underlying arterial disease and few medical comorbidities. More research efforts toward preventing limb loss and COVID-19 coagulopathy must be performed expeditiously to achieve a better understanding.
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Chang JC. Novel Classification of Thrombotic Disorders Based on Molecular Hemostasis and Thrombogenesis Producing Primary and Secondary Phenotypes of Thrombosis. Biomedicines 2022; 10:2706. [PMID: 36359229 PMCID: PMC9687744 DOI: 10.3390/biomedicines10112706] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 09/26/2022] [Accepted: 10/11/2022] [Indexed: 09/29/2023] Open
Abstract
Thrombosis, the common and deadliest disorder among human diseases, develops as a result of the intravascular hemostasis following an intravascular injury, which can be caused by a variety of trauma, non-traumatic insults or clinical illnesses. Thrombosis can occur at any location of the vascular system supplied by blood from the heart to large and smallest arterial and venous systems and may affect the function and anatomy of the organ and tissue. It more commonly occurs in the smaller circulatory system of the vascular tree such as arterioles and capillaries, and venules of the organs, especially in the brain, lungs, heart, pancreas, muscle and kidneys, and sinusoids of the liver. Thrombosis has been referred as the disease of "blood clots", which concept is incompletely defined, but represents many different hemostatic diseases from microthrombosis to fibrin clot disease, macrothrombosis, and combined micro-macrothrombosis. Thrombosis is produced following an intravascular injury via one or more combination of four different mechanisms of thrombogenesis: microthrombogenesis, fibrinogenesis, macrothrombogenesis and micro-macrothrombogenesis initiated by normal physiological hemostasis in vivo. The clinical phenotype expression of thrombosis is determined by: (1) depth of the intravascular wall injury, (2) extent of the injury affecting the vascular tree system, (3) physiological character of the involved vascular system, (4) locality of the vascular injury, and (5) underlying non-hemostatic conditions interacting with hemostasis. Recent acquisition of "two-path unifying theory" of hemostasis and "two-activation theory of the endothelium" has opened a new frontier in science of medicine by identifying the pathophysiological mechanism of different thrombotic disorders and also contributing to the better understanding of many poorly defined human diseases, including different phenotypes of stroke and cardiovascular disease, trauma, sepsis and septic shock, multiorgan dysfunction syndrome, and autoimmune disease, and others. Reviewed are the fundamentals in hemostasis, thrombogenesis and thrombosis based on hemostatic theories, and proposed is a novel classification of thrombotic disorders.
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Affiliation(s)
- Jae Chan Chang
- Department of Medicine, School of Medicine, University of California Irvine School of Medicine, Irvine, CA 92868, USA
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Arabi M, Heidari Beigvand H, Samimagham H, Salimi N, Kazemi Jahromi M. Upper Limb Ischemia Following COVID-19 Infection: A Case Report. Jundishapur J Microbiol 2022; 15. [DOI: 10.5812/jjm.122074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction: COVID-19 infection can cause a wide range of complications, from respiratory infection to skin rashes. Case Presentation: Here, we report a case of a 73-year-old woman with left brachial artery thrombosis 2 weeks after the onset of COVID-19 infection, leading to left upper limb ischemia. Conclusions: Given the life-changing nature of limb ischemia that can lead to amputation, it is crucial to consider it from the beginning of COVID-19 infection and think of preventive measures in this pandemic.
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Jongkind V, Earnshaw JJ, Bastos Gonçalves F, Cochennec F, Debus ES, Hinchliffe R, Menyhei G, Svetlikov AV, Tshomba Y, Van Den Berg JC, Björck M. Editor's Choice - Update of the European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia in Light of the COVID-19 Pandemic, Based on a Scoping Review of the Literature. Eur J Vasc Endovasc Surg 2022; 63:80-89. [PMID: 34686452 PMCID: PMC8418912 DOI: 10.1016/j.ejvs.2021.08.028] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 08/18/2021] [Accepted: 08/26/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To perform a scoping review of how patients with COVID-19 are affected by acute limb ischaemia (ALI) and evaluate the recommendations of the 2020 ESVS ALI Guidelines for these patients. METHODS Research questions were defined, and a systematic literature search was performed following the PRISMA guidelines. Abstracts and unpublished literature were not included. The definition of ALI in this review is in accordance with the ESVS guidelines. RESULTS Most identified papers were case reports or case series, although population based data and data from randomised controlled trials were also identified. In total, 114 unique and relevant papers were retrieved. Data were conflicting concerning whether the incidence of ALI increased, or remained unchanged, during the pandemic. Case reports and series reported ALI in patients who were younger and healthier than usual, with a greater proportion affecting the upper limb. Whether or not this is coincidental remains uncertain. The proportion of men/women affected seems unchanged. Most reported cases were in hospitalised patients with severe COVID-19. Patients with ALI as their first manifestation of COVID-19 were reported. Patients with ALI have a worse outcome if they have a simultaneous COVID-19 infection. High levels of D-dimer may predict the occurrence of arterial thromboembolic events in patients with COVID-19. Heparin resistance was observed. Anticoagulation should be given to hospitalised COVID-19 patients in prophylactic dosage. Most of the treatment recommendations from the ESVS Guidelines remained relevant, but the following were modified regarding patients with COVID-19 and ALI: 1) CTA imaging before revascularisation should include the entire aorta and iliac arteries; 2) there should be a high index of suspicion, early testing for COVID-19 infection and protective measures are advised; and 3) there should be preferential use of local or locoregional anaesthesia during revascularisation. CONCLUSION Although the epidemiology of ALI has changed during the pandemic, the recommendations of the ESVS ALI Guidelines remain valid. The above mentioned minor modifications should be considered in patients with COVID-19 and ALI.
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Affiliation(s)
- Vincent Jongkind
- Department of Vascular Surgery, Amsterdam University Medical Centres, Amsterdam, the Netherlands.
| | | | - Frederico Bastos Gonçalves
- NOVA Medical School, Universidade NOVA de Lisboa & Centro Hospitalar Universitário de Lisboa Central, Portugal
| | | | - E. Sebastian Debus
- Department for Vascular Medicine (Vascular Surgery, Angiology, Endovascular Therapy), University Heart & Vascular Centre, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Robert Hinchliffe
- Bristol Centre for Surgical Research, Bristol NIHR Biomedical Research Centre, Bristol, UK
| | - Gabor Menyhei
- Department of Vascular Surgery, University of Pecs, Pecs, Hungary
| | - Alexei V. Svetlikov
- Division of Cardio-Vascular of the North-Western Medical University named after II Mechnikov, St Petersburg, Russia
| | - Yamume Tshomba
- Unit of Vascular Surgery, Fondazione Policlinico Universitario Gemelli IRCCS, Roma - Università Cattolica del Sacro Cuore, Rome, Italy
| | - Jos C. Van Den Berg
- Service of Interventional Radiology Centro Vascolare Ticino Ospedale Regionale di Lugano and Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie Inselspital, Bern, Switzerland
| | - Martin Björck
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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Galyfos G, Sianou A, Frountzas M, Vasilios K, Vouros D, Theodoropoulos C, Michalopoulou V, Sigala F, Filis K. Acute limb ischemia among patients with COVID-19 infection. J Vasc Surg 2022; 75:326-342. [PMID: 34390791 PMCID: PMC8358086 DOI: 10.1016/j.jvs.2021.07.222] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 07/27/2021] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- George Galyfos
- Vascular Surgery Unit, First Department of Propedeutic Surgery, National and Kapodistrian University of Athens, Hippocration Hospital, Athens, Greece.
| | - Argiri Sianou
- Department of Microbiology, National and Kapodistrian University of Athens, Areteion Hospital, Athens, Greece
| | - Maximos Frountzas
- Vascular Surgery Unit, First Department of Propedeutic Surgery, National and Kapodistrian University of Athens, Hippocration Hospital, Athens, Greece
| | - Kotsarinis Vasilios
- Vascular Surgery Unit, First Department of Propedeutic Surgery, National and Kapodistrian University of Athens, Hippocration Hospital, Athens, Greece
| | - Dimitrios Vouros
- Vascular Surgery Unit, First Department of Propedeutic Surgery, National and Kapodistrian University of Athens, Hippocration Hospital, Athens, Greece
| | - Charis Theodoropoulos
- Vascular Surgery Unit, First Department of Propedeutic Surgery, National and Kapodistrian University of Athens, Hippocration Hospital, Athens, Greece
| | - Victoria Michalopoulou
- Vascular Surgery Unit, First Department of Propedeutic Surgery, National and Kapodistrian University of Athens, Hippocration Hospital, Athens, Greece
| | - Frangiska Sigala
- Vascular Surgery Unit, First Department of Propedeutic Surgery, National and Kapodistrian University of Athens, Hippocration Hospital, Athens, Greece
| | - Konstantinos Filis
- Vascular Surgery Unit, First Department of Propedeutic Surgery, National and Kapodistrian University of Athens, Hippocration Hospital, Athens, Greece
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Abstract
Hypercoagulation is a hallmark of both the novel coronavirus disease (COVID-19) and type 2 diabetes mellitus (T2DM). It increases the risk for vascular thrombosis, including peripheral artery diseases. Among others, acute limb ischemia (ALI) is one of most common complications that requires immediate and prompt treatments to reduce morbidity and mortality. However, the complex interplay between COVID-19, T2DM and its complications (e.g., diabetic nephropathy), and ALI creates a great challenge in the management of the disease. Here, we present a case of a 59-year-old diabetic female with progressive pain in her left leg in the last five years, which was significantly intensified following COVID-19 diagnosis. Bluish coloration, numbness and functional impairments were observed during examinations with no palpable pulsation on left posterior tibial and dorsalis pedis arteries. The patient also had diabetic nephropathy (stage III), hypoalbuminemia, anemia and a urinary tract infection that complicated the management of the disease. Due to the excruciating pain and the worsening of the limb conditions, right leg revascularization and left leg amputation were performed at day 14 after admission. Following the surgeries, no more pain was observed and patient was discharged for further follow-up at the outpatient clinic.
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Affiliation(s)
- Decsa Medika Hertanto
- Department of Internal Medicine, Faculty of Medicine, Airlangga University, Surabaya, Jawa Timur, 60132, Indonesia.,Department of Internal Medicine, Dr. Soetomo Hospital, Surabaya, Jawa Timur, 60286, Indonesia
| | - Henry Sutanto
- Department of Cardiology, Maastricht University, Maastricht, Limburg, 6229ER, The Netherlands.,Department of Physiology and Pharmacology, SUNY Downstate Medical Center, Brooklyn, New York, 11203, USA
| | - Soebagijo Adi
- Department of Internal Medicine, Faculty of Medicine, Airlangga University, Surabaya, Jawa Timur, 60132, Indonesia.,Division of Endocrinology, Diabetes and Metabolism, Department of Internal Medicine, Dr. Soetomo Hospital, Surabaya, Jawa Timur, 60286, Indonesia
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Attisani L, Pucci A, Luoni G, Luzzani L, Pegorer MA, Settembrini AM, Bissacco D, Wohlauer MV, Piffaretti G, Bellosta R. COVID-19 and acute limb ischemia: a systematic review. J Cardiovasc Surg (Torino) 2021; 62:542-547. [PMID: 34581552 DOI: 10.23736/s0021-9509.21.12017-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- Luca Attisani
- Vascular and Endovascular Surgery Unit, Poliambulanza Foundation Hospital, Brescia, Italy -
| | - Alessandro Pucci
- Vascular and Endovascular Surgery Unit, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Giorgio Luoni
- Vascular and Endovascular Surgery Unit, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Luca Luzzani
- Vascular and Endovascular Surgery Unit, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Matteo A Pegorer
- Vascular and Endovascular Surgery Unit, Poliambulanza Foundation Hospital, Brescia, Italy
| | | | - Daniele Bissacco
- Vascular Surgery Unit, IRCCS Ca Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Max V Wohlauer
- Vascular Surgery, University of Colorado, Denver, CO, USA
| | | | - Raffaello Bellosta
- Vascular and Endovascular Surgery Unit, Poliambulanza Foundation Hospital, Brescia, Italy
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Mohamed DZ, Ghoneim MES, Abu-Risha SES, Abdelsalam RA, Farag MA. Gastrointestinal and hepatic diseases during the COVID-19 pandemic: Manifestations, mechanism and management. World J Gastroenterol 2021; 27:4504-4535. [PMID: 34366621 PMCID: PMC8326263 DOI: 10.3748/wjg.v27.i28.4504] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2021] [Revised: 02/12/2021] [Accepted: 06/07/2021] [Indexed: 02/06/2023] Open
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is considered the causative pathogen of coronavirus disease 2019 (COVID-19) and has become an international danger to human health. Although respiratory transmission and symptoms are still the essential manifestations of COVID-19, the digestive system could be an unconventional or supplementary route for COVID-19 to be transmitted and manifested, most likely due to the presence of angiotensin-converting enzyme 2 (ACE2) in the gastrointestinal tract. In addition, SARS-CoV-2 can trigger hepatic injury via direct binding to the ACE2 receptor in cholangiocytes, antibody-dependent enhancement of infection, systemic inflammatory response syndrome, inflammatory cytokine storms, ischemia/reperfusion injury, and adverse events of treatment drugs. Gastrointestinal symptoms, including anorexia, nausea, vomiting, and diarrhea, which are unusual in patients with COVID-19, and some digestive signs may occur without other respiratory symptoms. Furthermore, SARS-CoV-2 can be found in infected patients' stool, demonstrating the likelihood of transmission through the fecal-oral route. In addition, liver function should be monitored during COVID-19, particularly in more severe cases. This review summarizes the evidence for extra-pulmonary manifestations, mechanisms, and management of COVID-19, particularly those related to the gastrointestinal tract and liver.
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Affiliation(s)
- Dina Zakaria Mohamed
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Tanta University, Tanta 31511, Egypt
| | - Mai El-Sayed Ghoneim
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, University of Sadat City, Menoufia 32632, Egypt
| | - Sally El-Sayed Abu-Risha
- Department of Pharmacology and Toxicology, Faculty of Pharmacy, Tanta University, Tanta 31511, Egypt
| | - Ramy Ahmed Abdelsalam
- Department of Pathology, Faculty of Medicine, Mansoura University, Mansoura 35511, Egypt
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Szeles A, El-Daher NT, Lachant N, Rizk TA. Acute limb ischemia and aortic mural thrombosis as primary manifestations of SARS-CoV-2. J Vasc Surg Cases Innov Tech 2021; 7:605-609. [PMID: 34316528 PMCID: PMC8299151 DOI: 10.1016/j.jvscit.2021.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 07/09/2021] [Indexed: 12/12/2022]
Abstract
A variable clinical presentation is emerging as a hallmark of the novel SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2). In addition to hypoxic respiratory failure, multiorgan dysfunction, and septic shock, significant thromboembolic complications posited to result from diffuse coagulopathy have been associated with this viral infection. We report on a unique primary manifestation of SARS-CoV-2 infection presenting as acute limb ischemia and aortic mural thrombosis without clinical evidence of pulmonary disease. Despite our best attempts at limb salvage with therapeutic anticoagulation, emergent aortoiliac and distal embolectomy, the patient developed bilateral dry gangrene and ultimately required lower extremity amputations.
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Affiliation(s)
- Andras Szeles
- Department of Medicine, Unity Hospital, Rochester Regional Health, Rochester NY
| | - Nayef T El-Daher
- Department of Medicine, Unity Hospital, Rochester Regional Health, Rochester NY
| | - Neil Lachant
- Department of Medicine, Hematology/Oncology, University of Rochester, Rochester NY
| | - Toufic A Rizk
- Vascular Surgery, Unity Hospital, Rochester Regional Health, Rochester NY
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Hattenbach LO, Feltgen N, Eter N, Al-Nawaiseh S, Chronopoulos A. Ophthalmic Outpatient and Inpatient Care Under Pandemic Conditions: Hygiene, Triage and New Challenges. Klin Monbl Augenheilkd 2021; 238:561-568. [PMID: 34020484 DOI: 10.1055/a-1487-1742] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND The progression of the COVID-19 pandemic has caused significant changes in the environment for outpatient and inpatient care in ophthalmology, with limitations on access to medical care but also new observations and challenges. We now describe major developments in recent months and provide an outlook on the expected consequences. METHODS PubMed literature search, clinical survey. RESULTS To date, the course of the COVID-19 pandemic has been characterised by several new but overall rare ocular manifestations, the ophthalmological shared management of COVID-19 patients on intensive care units, and a significant decrease in case numbers, associated with an increase in case severity and relative proportion of emergencies, as a result of delayed presentation of patients and reduced treatment adherence. With the introduction of hygiene measures and infection control procedures, ophthalmic patient care was maintained - including emergencies and urgent treatments. Due to the extensive postponement of elective surgeries, scarce therapeutic and health care professional resources, and the prioritisation of critically ill patients from other specialties, there is a reasonable likelihood that urgent treatments will be delayed as infection rates rise. CONCLUSION Outpatient and inpatient care in ophthalmology during the COVID-19 pandemic is primarily accompanied by additional organisational or medical challenges and a decline in case volume. Although to date emergency and urgent ophthalmic treatments have been maintained, long-term persistence of pandemic conditions will require additional strategies to provide continuation of ophthalmic care at the required level.
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Affiliation(s)
| | | | - Nicole Eter
- Klinik für Augenheilkunde, Universitätsklinikum Münster, Deutschland
| | - Sami Al-Nawaiseh
- Klinik für Augenheilkunde, Universitätsklinikum Münster, Deutschland
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Parekh YH, Altomare NJ, McDonnell EP, Blaser MJ, Parikh PD. Recurrence of Upper Extremity Deep Vein Thrombosis Secondary to COVID-19. Viruses 2021; 13:v13050878. [PMID: 34064763 PMCID: PMC8151248 DOI: 10.3390/v13050878] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 04/27/2021] [Accepted: 05/07/2021] [Indexed: 12/15/2022] Open
Abstract
Infection with SARS-CoV-2 leading to COVID-19 induces hyperinflammatory and hypercoagulable states, resulting in arterial and venous thromboembolic events. Deep vein thrombosis (DVT) has been well reported in COVID-19 patients. While most DVTs occur in a lower extremity, involvement of the upper extremity is uncommon. In this report, we describe the first reported patient with an upper extremity DVT recurrence secondary to COVID-19 infection.
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Affiliation(s)
- Yesha H. Parekh
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08901, USA; (Y.H.P.); (N.J.A.); (E.P.M.)
| | - Nicole J. Altomare
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08901, USA; (Y.H.P.); (N.J.A.); (E.P.M.)
| | - Erin P. McDonnell
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ 08901, USA; (Y.H.P.); (N.J.A.); (E.P.M.)
| | - Martin J. Blaser
- Center for Advanced Biotechnology and Medicine, Rutgers University, New Brunswick, NJ 08901, USA
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, Piscataway, NJ 08851, USA
- Correspondence: (M.J.B.); (P.D.P.)
| | - Payal D. Parikh
- Department of Medicine, Rutgers Robert Wood Johnson Medical School, Piscataway, NJ 08851, USA
- Correspondence: (M.J.B.); (P.D.P.)
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Abstract
The optimal management strategy of acute limb ischemia in non-ventilated patients with COVID-19 is uncertain. We propose that non-ventilated patients who develop COVID-19 related spontaneous arterial thrombosis with associated limb threat may be best suited with percutnaeous revascularization to achieve limb salvage. Herein we describe 5 cases of patients who had severely threatened limbs with complete thrombosis of all 3 tibial arteries who were treated with percutaneous revascularization. All 5 patients were felt to be facing inevitable amputation without revascularization should they survive their COVID hospitalization. We were able to achieve limb salvage in all 5 patients selected for therapy, although 2 ultimately succumbed to respiratory failure.
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Affiliation(s)
- Margaret Aasen
- 12248Stritch School of Medicine, Loyola University Chicago, IL, USA
| | - Matthew Blecha
- Division of Vascular Surgery and Endovascular Therapy, Loyola University Chicago, IL, USA
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14
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Demir KK, Simard C, Lipes J, Yang SS. Life and Limb: a Case of COVID-19-Associated Multisystem Thrombosis and Review of the Literature. J Gen Intern Med 2021; 36:802-806. [PMID: 33403619 PMCID: PMC7784618 DOI: 10.1007/s11606-020-06496-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 12/17/2020] [Indexed: 12/02/2022]
Affiliation(s)
- Koray K Demir
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Camille Simard
- Department of Medicine, McGill University, Montreal, QC, Canada
| | - Jed Lipes
- Department of Medicine, Division of Critical Care, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Stephen Su Yang
- Department of Anesthesia, Division of Critical Care, Jewish General Hospital, McGill University, Montreal, QC, Canada.
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Touzani S, Haddari F, Elbouazzaoui A, Houari N, Boukatta B, Kanjaa N. Acute Limb Ischemia in Critically ill COVID-19 Patients: a Case Series and Literature Review. JMSR 2021. [DOI: 10.46327/msrjg.1.000000000000191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: The vascular burden increased by COVID-19 infection and including acute limb ischemia (ALI) quickly emerged as a major medical challenge with devastating consequences such as limb loss, multiorgan dysfunction and death. We report a case series of COVID-19 infection associated with ALI to raise awareness and knowledge towards this life-threatening association. Methods: COVIDS-19 patients with acute limb ischemia (ALI) managed in a Moroccan 14 beds COVID-19 ICU between March 2020 and January 2021, were reviewed. Data collected included demographics, clinical presentation, treatments and outcomes. Results: Over the 10-month period, our ICU cared for 407 hospitalized patients with confirmed COVID-19. A total of 6 COVID-19 patients with ALI were identified. The mean age was 61 years (52 - 70) and 5 were men. The most common preexisting condition was diabetes (50%). The mean CRP level was 219 mg/L. Five patients had thrombus in multiple locations. No concomitant deep vein thrombosis was identified. Four patients presented with signs of acute No arterial ischemia with or without respiratory symptoms and were subsequently diagnosed with COVID-19. The remaining two patients developed ischemia during hospitalization. Mean SOFA score was 5 (2 -9). Respiratory support, corticosteroids and heparin therapies were used in all patients. Intubation and vasopressors were required in four patients. Revascularization was performed in five patients and reintervention was necessary in three cases. Four patients died in the ICU while two were successfully discharged. Conclusion: ALI in COVID-19 patients is a challenging life-threatening vascular emergency that requires appropriate multidisciplinary management (intensivists, anesthesiologists, vascular surgeons and interventionists, radiologists, haematologists…) and further studies focused on anticoagulation.
Keywords: Acute Limb ischemia, Coagulopathy, COVID-19, SARS-CoV-2, Thrombosis
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Ramachandran R, Vasudevan Pillai A, Raja S, Sailesh S. Axillary artery thrombosis resulting in upper limb amputation as a COVID-19 sequela. BMJ Case Rep 2021; 14:e240981. [PMID: 33500313 PMCID: PMC7839882 DOI: 10.1136/bcr-2020-240981] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2021] [Indexed: 02/06/2023] Open
Abstract
Novel COVID-19 continues to intrigue medical professionals with its varied presentations. Though it affects the respiratory tract primarily, thrombogenesis has been the Achilles' heel. A 44-year-old man diagnosed with COVID-19 presented with upper limb pain at a local hospital and was found to have thrombosis of the right axillary artery. Despite a successful embolectomy at the local hospital, there was re-occlusion of the axillary artery and the limb became ischaemic. He was referred to our institution by which time the limb became gangrenous above the elbow and had to be amputated. Extensive sloughing of the nerves was also seen in the local area. Hypercoagulability presenting with various manifestations is common in COVID-19 and needs early anticoagulation. We present this asymptomatic patient who lost a limb to this COVID-19 sequelae.
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Affiliation(s)
- Riju Ramachandran
- General Surgery, Amrita School of Medicine, Amrita Viswavidyapeetham, Kochi, India
| | | | - Suyambu Raja
- General Surgery, Amrita School of Medicine, Amrita Viswavidyapeetham, Kochi, India
| | - Sailakshmi Sailesh
- General Surgery, Amrita School of Medicine, Amrita Viswavidyapeetham, Kochi, India
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Sánchez JB, Cuipal Alcalde JD, Ramos Isidro R, Luna CZ, Cubas WS, Coaguila Charres A, Gutiérrez JE, Ochoa JD, Arias PF. Acute Limb Ischemia in a Peruvian Cohort Infected by COVID-19. Ann Vasc Surg 2020; 72:196-204. [PMID: 33388408 PMCID: PMC7836937 DOI: 10.1016/j.avsg.2020.12.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 12/13/2020] [Accepted: 12/22/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) infection can cause alterations in the coagulation mechanism conditioning thrombotic phenomena such as acute limb ischemia (ALI) as the only manifestation of the infection. The aim of the study was to describe clinical and surgical characteristics of a group of patients infected with severe acute respiratory syndrome coronavirus 2 who presented ALI in the context of the COVID-19 pandemic at Lima, Peru. METHODS A multicenter, observational, and retrospective study was performed in six general hospitals, from March to July 2020. The variables considered were the pathological history and associated habits, laboratory tests, the severity of COVID-19 infection and ALI, the anatomic location of the lesion, treatment, evolution, and discharge conditions. RESULTS Thirty patients with ALI infected with COVID-19 were evaluated. Their mean age was 60 ± 15 years, the condition being more frequent in men (76.6%). The main comorbidities were arterial hypertension (33.3%), obesity (33.3%), and diabetes mellitus 2 (26.6%). There were 23.3% asymptomatic patients, and their only manifestation was ALI. Rutherford IIA and IIB stage included 93.2% of patients. The most frequent location of the thrombosis was the lower limbs (73.3% vs. 26.6%). Thrombectomy was performed in 76.6% of the patients, and amputation (primary and secondary) was performed in 30% of the patients. The mortality rate was 23.3%, all of it because of acute respiratory distress syndrome. CONCLUSIONS ALI is a vascular pathology associated with embolic and thrombotic processes. COVID-19 infection can cause severe alterations in coagulation mechanisms, leading some patients to present severe acute arterial complications such as thrombosis, as the only associated manifestation. We report a younger cohort than those described in other studies and with a high frequency of amputations despite adequate surgical treatment.
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Affiliation(s)
- Juan Bautista Sánchez
- Vascular and Endovascular Surgery Unit, Cardiac and Vascular Surgery Service, Guillermo Almenara Irigoyen National Hospital, Lima, Peru.
| | - Juan Diego Cuipal Alcalde
- Vascular and Endovascular Surgery Unit, Cardiac and Vascular Surgery Service, Guillermo Almenara Irigoyen National Hospital, Lima, Peru
| | - Rossi Ramos Isidro
- Vascular and Endovascular Surgery Unit, Cardiac and Vascular Surgery Service, Guillermo Almenara Irigoyen National Hospital, Lima, Peru
| | - Carlos Zúñiga Luna
- Vascular and Endovascular Surgery Unit, Cardiac and Vascular Surgery Service, Guillermo Almenara Irigoyen National Hospital, Lima, Peru
| | - W Samir Cubas
- Vascular and Endovascular Surgery Service, Thoracic and Cardiovascular Surgery Department, Edgardo Rebagliati Martins National Hospital, Lima, Peru
| | | | - José Egoávil Gutiérrez
- Thorax and Cardiovascular Surgery Service, Cayetano Heredia National Hospital, Lima, Peru
| | - Juan David Ochoa
- Thoracic and Cardiovascular Surgery Department, Hipolito Unanue National Hospital, Lima, Peru
| | - Patricia Fernández Arias
- Thorax and Cardiovascular Surgery Department, Luis N. Saenz National Police Hospital, Lima, Peru
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Abstract
Arterial thrombosis is rarely reported in relation to COVID-19 patients. It occurs mostly in critical patients especially those with acute respiratory distress syndrome and patients in intensive care units. The cause of arterial thrombosis is mostly related to a cytokine storm. However, limited studies are available regarding arterial thrombosis in COVID-19 disease. Here, we present a case of lower limb ischemia in a moderately symptomatic COVID-19 patient in Iraq within three days after recovery from COVID-19. The patient presented with severe right lower limb pain, forefoot, cyanosed toes, and lower limb ischemia was diagnosed by physical examination and ultrasound. The patient was successfully treated by anticoagulant drugs. Our case alerts healthcare workers that they need to be more cautious of life threatening COVID-19 complications in order to begin early and effective preventive measures.
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