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

Abstract

Objectives Perform a scoping review how COVID-19 patients are affected by acute limb ischaemia (ALI). Evaluate the recommendations of the 2020 ESVS ALI Guidelines for these patients. Methods Research questions were defined, followed by a systematic literature search according to the PRISMA guideline. Abstracts and unpublished literature were not included. The definition of ALI accords to ESVS guidelines. Results Most identified papers were case reports or case series; population-based data and data from randomised controlled trials were also identified, 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, and a greater proportion affecting the upper limb. Whether 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 hospitalized COVID-19 patients in prophylactic dosage. Most of the treatment recommendations of the ESVS Guidelines remained relevant, but the following were modified regarding COVID-19 patients with 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. 3) 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 COVID-19 patients with ALI.

Treating Peripheral Arterial Occlusive Disease and Acute Limb Ischemia During a COVID-19 Pandemic in 2020

“…Interestingly, the number of interventions for ALI was not significantly altered in the present study. Since the effect of SARS-CoV-2 on the prevalence of arterial thrombosis is still uncertain ( 14 ), our findings might help comprehend this along with data from future publications.…”

An Observational Study on Patients with Acute Limb Ischemia and SARS-CoV-2 Infection: Early and Late Results in Limb Salvage Rate

“…The recommendations regarding the anticoagulation treatment in patients with ALI and SARS-CoV-2 infection are not well established yet. In a study on 20 patients who underwent revascularization, the usage of systemic heparin was associated with increased survival [38,39]. In this study, all the patients received low molecular weight heparin after revascularization, and none of them required reintervention, which leads to the possibility that heparinization prevents recurrent thrombosis and improves the rate of survival and limb salvage.…”

Thrombosis of Medium-Sized and Large Arteries During Covid-19 Infection: Results of the COVIVASC Study

“…An update of the Guidelines of the European Society for Vascular Surgery (ESVS) was made regarding the management of acute ischemia related to Sars-Cov2/COVID-19 and recommends the realization of an angio-CT including the aorta in its totality and the iliac arteries. 23 Avila at al. reviewed 95 studies of the literature and reported that the lower limb arteries and the abdominal or thoracic aorta were the most frequent localizations of acute thrombotic events of arterial origin.…”