COVID-19 and acute limb ischemia: a systematic review.

INTRODUCTION: The main goal of this systematic review was to analyze the outcomes of acute limb ischemia (ALI) in patients suffering from the novel Coronavirus: COVID-19 (SARS-CoV-2). EVIDENCE 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. Most 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 condition and extension of the thrombosed segment. ALI in COVID-19 patients is associated with high risk of failure of revascularization and perioperative mortality.

Outcomes of stent-graft repair for anastomotic femoral pseudoaneurysm. A case series.

OBJECTIVE: This study aims to report a case series of anastomotic femoral pseudoaneurysms (PSA) treated with stent-grafting (SG) in patients at high-risk for the open surgical approach. METHODS: It is a retrospective, observational cohort study. Between 1 January 2002 and 1 April 2020, post-hoc analysis of the database including patients who received repair for femoral PSA identified those treated with SG. All but one patient were approached through a contralateral percutaneous transfemoral access, and the SG was always deployed from the common femoral artery to the profunda femoris artery. For this study, primary outcomes of interest were early (≤ 30 days) survival and patency rate. RESULTS: We identified 10/823 cases of the entire PSA cohort (1.2%). There were 9 men and 1 woman: the mean age was 76 years ± 9 (range: 64-92). Urgent intervention was performed in 4 patients. The median operative time was 30 min (IQR: 25-36). Access-related complication was never observed. In-hospital mortality occurred in 1 patient due to novel coronavirus-19-related pneumonia. Median follow-up was 24 months (IQR: 12-37); 5 patients died. At the last radiologic follow-up available, all SGs were patent without necessity of reintervention. CONCLUSION: Stent-graft repair for anastomotic femoral PSA may be considered a reasonable alternative for patients at high-risk for open surgical repair.

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.

COVID-19 acute respiratory distress syndrome: can iloprost have a role for the treatment?

Pulmonary infection of 2019-nCoV can frequently induce acute respiratory distress syndrome (ARDS) with partial pressure of arterial oxygen/fraction of inspired oxygen ratio (pO2/FiO2) of less than 300 mmHg. Moreover, it can be complicated with cardiac injury or arrhythmia, microvascular and large-vessel thrombosis. We describe a case of a patient with COVID19-ARDS and concomitant critical ischemia of the limbs. Iloprost treatment, an analogue of a prostacyclin PGI2, was started for residual left forefoot ischemia after surgical thromboembolectomy. Unexpectedly, we documented improvement of respiratory performance and lung high resolution computed tomography (HRCT) showed significant regression of the diffuse pulmonary ground-glass opacity. The hypothetical mechanism is that iloprost can enhance perfusion preferentially to well-ventilated lung regions, reduce pressures of peripheral pulmonary vessels and induce reduction of lung interstitial edema. In addition, iloprost antithrombotic effect, endothelial damage repairing and neo-angiogenesis activity could play a relevant role.

Acute limb ischemia in patients with COVID-19 pneumonia.

Objective: The aim of our study was to determine the incidence, characteristics, and clinical outcomes of patients with the novel coronavirus (COVID-19) infection who had presented with and been treated for acute limb ischemia (ALI) during the 2020 coronavirus pandemic. Methods: We performed a single-center, observational cohort study. The data from all patients who had tested positive for COVID-19 and had presented with ALI requiring urgent operative treatment were collected in a prospectively maintained database. For the present series, successful revascularization of the treated arterial segment was defined as the absence of early (<30 days) re-occlusion or major amputation or death within 24 hours. The primary outcomes were successful revascularization, early (≤30 days) and late (≥30 days) survival, postoperative (≤30 days) complications, and limb salvage. Results: We evaluated the data from 20 patients with ALI who were positive for COVID-19. For the period from January to March, the incidence rate of patients presenting with ALI in 2020 was significantly greater than that for the same months in 2019 (23 of 141 [16.3%] vs 3 of 163 [1.8%]; P < .001)]. Of the 20 included patients, 18 were men (90%) and two were women (10%). Their mean age was 75 ± 9 years (range, 62-95 years). All 20 patients already had a diagnosis of COVID-19 pneumonia. Operative treatment was performed in 17 patients (85%). Revascularization was successful in 12 of the 17 (70.6%). Although successful revascularization was not significantly associated with the postoperative use of intravenous heparin (64.7% vs 83.3%; P = .622), no patient who had received intravenous heparin required reintervention. Of the 20 patients, eight (40%) had died in the hospital. The patients who had died were significantly older (81 ± 10 years vs 71 ± 5 years; P = .008). The use of continuous postoperative systemic heparin infusion was significantly associated with survival (0% vs 57.1%; P = .042). Conclusions: In our preliminary experience, the incidence of ALI has significantly increased during the COVID-19 pandemic in the Italian Lombardy region. Successful revascularization was lower than expected, which we believed was due to a virus-related hypercoagulable state. The use of prolonged systemic heparin might improve surgical treatment efficacy, limb salvage, and overall survival.