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

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.

Aorto Femoral Bypass Graft in Chronic Limb Ischemia Patient

A 44-year-old man was admitted to hospital to be performed re-thrombectomy after previously performed thrombectomy at the referring hospital but did not show clinical improvement. CT angiography results before re-thrombectomy showed a central thrombus measuring 1.1 cm in diameter, and an impression of 2.6 cm long at the branching of the right external Iliaca artery which caused total obstruction of the right illiaca external artery to the distal. Aortofemoral bypass graft surgery is a procedure utilized commonly for the treatment of aortoiliac occlusive disease. The treatment given to manage symptoms if medical management or minimally invasive therapy, such as balloon angioplasty and stenting, was unsuccessful or unsuitable for the patient. Aortofemoral bypass graft surgical procedure was performed on the patient. However, post procedure angiography showed no visible flow through the newly placed graft. A repair graft procedure was planned for the patient, but the patient refused to undergo further surgical procedures.

ROLE OF PREOPERATIVE EPIDURAL ANALGESIA IN POSTOPERATIVE OUTCOME OF PATIENTS WITH CHRONIC LIMB ISCHEMIA AND REST PAIN

Introduction:Rest pain in patients with chronic limb ischemia is very severe and intolerable one, hence it is often quoted as cry of dying nerves. All these patients require highly effective analgesia for control of pain. Epidural analgesia is known for its effective analgesic property. Its role in post operative period is well documented and known. But its role in preoperative period for these patients is poorly understood. Here we analyze role of preoperative epidural analgesia in postoperative outcome of patients with chronic limb ischemia and rest pain. Material and Methods:It is a prospective study done in 40 patients which analyze role of preoperative epidural analgesia in postoperative outcome of patients with chronic limb ischemia and rest pain who are undergoing bypass revascularization procedures. Here 20 patients each separated in two groups, group 1 – those received preoperative epidural analgesia for 48 hours prior to surgery and group 2 those who not received preoperative epidural analgesia. Results:It was found postoperative wound infections, limb salvage rates and adverse myocardial events were lower in group 1 patients those received preoperative epidural analgesia. Conclusion:Hence preoperative epidural analgesia has beneficial role in postoperative outcome of patients with chronic limb ischemia and rest pain.