key: cord-0811078-89p2q16g
authors: Patelis, Nikolaos; Bisdas, Theodosios; Tsiachris, Dimitrios; Stefanadis, Christodoulos I.
title: The role of vascular surgeons in the treatment of COVID-19-associated pulmonary embolism
date: 2020-06-01
journal: J Vasc Surg
DOI: 10.1016/j.jvs.2020.05.050
sha: a1262f10c745dd8943c90492822ad58fd733d8ac
doc_id: 811078
cord_uid: 89p2q16g

nan

As the world is currently going through a pandemic caused by the Severe Acute Respiratory 1 Syndrome COrona Virus 2 (SARS-COV-2), the international medical community is collecting 2 data on COrona VIrus Disease . 3

In this battle, vascular surgeons are not directly involved in the diagnosis and/or treatment of 4 COVID-19. Their role is still to be determined, mainly by examining whether they could 5 intervene in cases of Pulmonary Embolism (PE) caused by severe COVID-19 infection. This is 6 exactly the point that a vascular surgeon should join efforts to combat this infection and possibly 7 save patients in a dire situation. 8 PE is a potentially lethal form of venous thromboembolism with a non-specific clinical 9

presentation and a rather challenging diagnosis. The number of diagnosed PE cases have been 10 continually rising, mainly due to the introduction improved diagnostic work-up and increased 11 awareness from medical personnel. Septic PE (SPE) is a form of secondary PE and alike PE its 12 diagnosis is challenging. 13

It is already described that Disseminated Intravascular Coagulation (DIC) can occur in patients 14 with severe COVID-19 leading to SPE. 1,2,3 COVID-19-related SPE is already described as a 15 lethal complication and a negative prognostic factor. 4 Published data on COVID-19-related SPE 16 is still limited to a small number of case reports. 17

Thrombolysis (CDT) and Surgical ThrombEctomy (STE). 5 SF shows both high survival rate and 19 significant bleeding risk for stable PE patients. SF is recommended in high-risk patients and in 20 deteriorating patients. STE is recommended in high-risk PE patients with contraindications for 21 SF or when SF has already failed. CDT (including Aspirational Thrombectomy or AT) seems to 22 have more benefits than risks for the patient compared to STE and it is considered an alternative 1 to STE when there is contraindication for SF or when SF has failed. 2

Very limited data exist regarding SPE treatment. Therefore, it should not come to our surprise 3 that SPE is not part of any society's guidelines and any treatment is based on PE data. 4

Anticoagulation and SF can be performed by physicians other than vascular surgeons. On the 5 other hand, the two methods used in PE patients who saw little or no benefit from 6 anticoagulation -STE and CDT -could be performed by vascular surgeons. In COVID-19 7 patients, any CDT technique could be of great clinical benefit as it improves pulmonary 8 circulation without the risks of SF or STE. Most CDT techniques are performed in existing set-9 ups of specialized centers by multidisciplinary PE response teams consisting of cardiologists, 10 interventional radiologists, vascular surgeons, intensive care physicians and pulmonary 11 specialists. These teams rapidly evaluate the frail or quickly deteriorating patient, then choose 12 the optimal technique for maximum patient benefit and finally execute the plan. 13

Despite lack of solid-based evidence regarding SARS-COVID-2, COVID-19 patients presenting 14

with SPE should receive life-saving pulmonary reperfusion performed by an experienced 15 vascular surgeon as a member of a multidisciplinary team. 16

Prominent changes in blood coagulation of patients with 19 SARS-CoV-2 infection

Septic pulmonary embolisms as a cause of 21 acute respiratory distress syndrome