key: cord-0983257-tj97q2py
authors: Valdivia, Andrés Reyes; Olmos, Cristina Gómez; Guaita, Julia Ocaña; Zúñiga, Claudio Gandarias
title: Cardiovascular examination should also include peripheral arterial evaluation for COVID-19 patients
date: 2020-04-30
journal: J Vasc Surg
DOI: 10.1016/j.jvs.2020.04.494
sha: 9e15032190d56b65505f6fd1662d7c244174f0e9
doc_id: 983257
cord_uid: tj97q2py

nan

The global impact of coronavirus disease (COVID-19) on vascular surgical services has been 9 initially addressed by Ng et al 1 . This change in how vascular surgery departments are adapting to 10 the ongoing scenario reveals a clear trend toward providing urgent care, as previously suggested 11 by some vascular communities 2 . Additionally, along that line, an "endovascular first-line 12 approach" seems reasonable because less in-hospital resources are required. 13 14 Spain has been especially affected, with nearly 15,000 deaths and 150,0000 positive cases. 15

Interestingly, nearly 20% of these are healthcare workers, which is related to an extreme lack of 16 personal protection equipment (PPE) and protection strategies. All Spanish national efforts are 17 currently directed toward stopping disease propagation and diminishing disease impact, leading 18 to unprecedented cooperation between public and private centers in attempts to provide care to 19 all who need it. 20

The cardiovascular (CV) effect of COVID-19 is currently under study. Some reports describe 22 acute coronary syndromes, arrhythmias and/or myocarditis due to the systemic inflammatory 23 3 response as well as localized vascular inflammation 3 . 1 2 Although substantial attention is directed toward evaluating the relationship between COVID-19 3 and myocardial disease 4,5 , we should not forget the global picture of the CV pathology and its 4 potential inducement of peripheral arterial disease (PAD). 5 6 Table I and II summarize four cases presenting with acute critical limb ischemia (ACLI) in 7 patients testing COVID-19 (+) with no previous vascular consultations or symptoms. We 8 identified a delayed diagnosis for the entire group. Either the patients were extremely fearful 9 about coming to the hospital or were underdiagnosed during hospitalization, as confirmed with 10 written commentary from nurses. An arterial thrombotic event presented in two COVID-19 11 patients who were asymptomatic despite testing positive for the disease. Blood testing 12 demonstrated a high inflammatory response in all of these patients (D-dimer, CRP) that was 13 significantly higher in those who were hospitalized with active and severe pneumonia. 14 Interestingly, pro-calcitonin values were normal in all of these patients, indicating an evolving 15 inflammatory condition. Although no strong conclusions can be drawn from this initial 16 description, it may serve as guidance for future studies seeking to improve PAD identification. 17 18 Clinicians involved in PAD care understand that timing is a key factor in limb salvage and ACLI 19 patient survival. These delayed presentations clearly demonstrate a population that is in fear of 20 presenting to an overwhelmed health system. The underdiagnoses in hospitalized patients could 21 be related to incomplete physical examinations in poorly communicating isolated elderly patients 22

(who may already have oxygen support and painkillers to treat high grade fever). These 23 underdiagnoses could also be related to the aforementioned lack of PPE that currently affects the 1 entire healthcare system. 2

We recognize the difficulty in diagnosis and therefore the late timing of disease identification for 4 those who are confined at home. Telemedicine and teleconsultations may be a game changer for 5 those patients. LMWH alone 2 daysclinical improvement * includes respiratory or fever, COPD = chronic obstructive pulmonary disease; DM = diabetes mellitus; HT = hypertension; PV= polycythemia; LMWH = low molecular weight heparin; DIC = disseminated intravascular coagulopathy; MOF = multiorgan failure, SFA= superficial femoral artery.

The Global Impact of COVID-17 19 on Vascular Surgical Services

American College of Surgeons. COVID-19: Recommendations for Management of 21

Elective Surgical Procedures