Chronic limb ischemia manifestation in COVID-19 infection: awareness and treatment in primary care

Abstract

Chronic limb ischemia (CLI) is a type of peripheral arterial disease (PAD) that is still underdiagnosed and undertreated despite the increasing incidence, thus becoming a global health burden. And CLI reflects the local manifestations of a lethal systemic disease — atherosclerosis. If left untreated, chronic limb ischemia can result in major limb loss. In this pandemic era, limb ischemia has become one of several clinical manifestations that occur in patients with COVID-19 infection. Systemic inflammation in COVID-19 infection, direct viral infection, hypercoagulable state, and hyperinflammatory response are responsible for damage to the arterial system, causing endothelial dysfunction. Diagnosing PAD has become a challenge especially in the early stage and in the asymptomatic phase. The untreated condition could lead to the development of CLI. The primary physicians in the primary health facilities hold an important role in the early diagnosis and management of patients with CLI symptoms or with risk factors of CLI, especially in patients who have experienced COVID-19 infection. Due to the limitation of diagnostic testing modalities at primary health facilities, the physician can assess the ankle-brachial index (ABI) to determine the presence of CLI. Management of the disease is different for every patient and is customized based on the other comorbidities. Risk factors should be controlled in order to achieve a better outcome. A good management strategy will improve the quality of life of the patient. This review will discuss the occurrence of CLI in COVID-19 infection.

Distinct Features of Vascular Diseases in COVID-19

“…Inhibition of endogenous anticoagulant proteins and an increase in plasminogen activator inhibitor I and tissue factor were involved. 148 , 154 , 155 …”

“… 163 In symptomatic patients, structured exercise therapy can reduce claudication. 154 Physical exercise can be performed at home and may benefit PAD patients in the COVID-19 era. 145 , 164 COVID-19 patients with comorbidities should be screened for pre-existing PAD.…”

“… 123 , 126 The standard approach to control comorbidities should be applied according to the guidelines. 146 , 154 , 165 …”

“…In patients with critical limb ischemia, the aim is to reduce mortality and to prevent limb amputation and restore mobility. 154,[160][161][162] Lifestyle modifications by increasing physical activity, adopting healthy eating habits, and managing comorbidities, form the first-line therapy. 163 In symptomatic patients, structured exercise therapy can reduce claudication.…”