IPC23 - Post COVID-19 Arterial Thrombosis: A Systematic Review

Objectives: COVID-19 is associated with coagulation defects, including endothelial dysfunction, inflammation, hypoxia, cytokine release, and hypercoagulability. We aimed to summarize the available cases of arterial peripheral thrombosis in the setting of post-infection COVID-19 period and the use of biomarkers and related pharmacological therapies to describe the better medical and surgical treatment based on the reported outcomes.

Methods: We executed a systematic review following the 2020 PRISMA guidelines. We searched on PubMed, Embase, Scopus, and the Cochrane Library for studies published from March 2020 up to September of 2021 with a serological confirmation of a resolved SARS-CoV-2 infection. Related questions regarding high-yield endpoints included the following: location of the thrombosis, amputation, re-intervention rates, mortality, anticoagulants, and biomarkers.

Results: Out of 398 matching results, 23 papers met the inclusion criteria of Post-COVID thrombosis; arterial; venous; peripheral; cured. The literature review includes 12 case reports, 3 incidence reports, 3 literature reviews, 2 meta-analyses, 1 observational cohort study, and 2 prospective analyses. The overall presentation consisted of peripheral arterial thrombosis (33.3%), venous thrombosis (63.2%), and mixed events (3.5%). Most of the articles reported the used Low-Molecular-Weight-Heparin (LMWH) monotherapy as part of the medical management; There was no difference in the usage of Clopidogrel and ASA as antiplatelet. Other pharmacological alternatives were non-Fraction-Heparin, enoxaparin, warfarin, Rivaroxaban, and Apixaban. Open thrombectomy was the most common procedure used for COVID thrombosis complications (40%), with a mortality of 27.2%. Endovascular thrombectomy (15%), followed by amputation (12.5%), exploratory laparotomy (5%), and endarterectomy (2.5%). We found 38 reported biomarkers which were classified in 7 categories related to an inflammatory process, coagulation time, clotting factors, cardiorespiratory, kidney function, metabolic profile, and autoimmunity. An initial D-dimer level above 1.250 ng/mL may identify COVID-19 patients at risk for arterial thrombotic events. Additional endpoints were associated with increased Creatinine, IL-6, IP-10, D-Dimer, and C-Reactive Protein.

Conclusions: COVID-19 infection is associated with a high risk for arterial and venous post-thrombotic complications, a variable clinical and anatomical presentation, high mortality, and amputation risk. Microcirculatory alterations can be reflected in a panel of biomarkers. The medical and surgical management of these patients may depend on the availability of resources regarding the context of medical attention. Nevertheless, considering the highly inflammatory context, endovascular interventions with less systemic stress should be considered additionally to thromboprophylaxis measurements.