<?xml version="1.0" encoding="UTF-8"?>
<!DOCTYPE article PUBLIC "-//NLM//DTD JATS (Z39.96) Journal Publishing DTD v1.2d1 20170631//EN" "JATS-journalpublishing1.dtd">
      <JournalTitle>Journal of Medical and Surgical Research</JournalTitle>
      <Volume-Issue>Vol. VII, n 3</Volume-Issue>
      <Season>February 2021</Season>
      <ArticleType>JMSR Anesthesiology and IC</ArticleType>
      <ArticleTitle>Acute Limb Ischemia in Critically ill COVID-19 Patients: a Case Series and Literature Review</ArticleTitle>
      <Abstract>Background: The vascular burden increased by COVID-19 infection and including acute limb ischemia (ALI) quickly emerged as a major medical challenge with devastating consequences such as limb loss, multiorgan dysfunction and death. We report a case series of COVID-19 infection associated with ALI to raise awareness and knowledge towards this life-threatening association. Methods: COVIDS-19 patients with acute limb ischemia (ALI) managed in a Moroccan 14 beds COVID-19 ICU between March 2020 and January 2021, were reviewed. Data collected included demographics, clinical presentation, treatments and outcomes. Results: Over the 10-month period, our ICU cared for 407 hospitalized patients with confirmed COVID-19. A total of 6 COVID-19 patients with ALI were identified. The mean age was 61 years (52 - 70) and 5 were men. The most common preexisting condition was diabetes (50%). The mean CRP level was 219 mg/L. Five patients had thrombus in multiple locations. No concomitant deep vein thrombosis was identified. Four patients presented with signs of acute No arterial ischemia with or without respiratory symptoms and were subsequently diagnosed with COVID-19. The remaining two patients developed ischemia during hospitalization. Mean SOFA score was 5 (2 -9). Respiratory support, corticosteroids and heparin therapies were used in all patients. Intubation and vasopressors were required in four patients. Revascularization was performed in five patients and reintervention was necessary in three cases. Four patients died in the ICU while two were successfully discharged. Conclusion: ALI in COVID-19 patients is a challenging life-threatening vascular emergency that requires appropriate multidisciplinary management (intensivists, anesthesiologists, vascular surgeons and interventionists, radiologists, haematologists…) and further studies focused on anticoagulation.</Abstract>
      <Keywords>Acute Limb ischemia, Coagulopathy,  COVID-19, SARS-CoV-2, Thrombosis</Keywords>
        <Abstract>https://journal-jmsr.net/ubijournal-v1copy/journals/abstract.php?article_id=9574&amp;title=Acute Limb Ischemia in Critically ill COVID-19 Patients: a Case Series and Literature Review</Abstract>
        <References>Leisman DE, Deutschman CS, Legrand M. Facing COVID-19 in the ICU: vascular dysfunction, thrombosis, and dysregulated inflammation. Intensive Care Med. 2020 Jun; 46(6):1105-1108.&#13;
	Laband;ograve; N, Ohnuki H, Tosato G. Vasculopathy and Coagulopathy Associated with SARS-CoV-2 Infection. Cells. 2020 Jun 30;9(7):1583.&#13;
	Helms J, Tacquard C, Severac F, Leonard-Lorant I, Ohana M, Delabranche X, Merdji H, Clere-Jehl R, Schenck M, Fagot Gandet F, Fafi-Kremer S, Castelain V, Schneider F, Grunebaum L, Angland;eacute;s-Cano E, Sattler L, Mertes PM, Meziani F; CRICS TRIGGERSEP Group (Clinical Research in Intensive Care and Sepsis Trial Group for Global Evaluation and Research in Sepsis). High risk of thrombosis in patients with severe SARS-CoV-2 infection: a multicenter prospective cohort study. Intensive Care Med. 2020 Jun;46(6):1089-1098.&#13;
	Klok FA, Kruip MJHA, van der Meer NJM, Arbous MS, Gommers DAMPJ, Kant KM, Kaptein FHJ, van Paassen J, Stals MAM, Huisman MV, Endeman H. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res. 2020 Jul;191:145-147.&#13;
	Goldman IA, Ye K, Scheinfeld MH. Lower-extremity Arterial Thrombosis Associated with COVID-19 Is Characterized by Greater Thrombus Burden and Increased Rate of Amputation and Death. Radiology. 2020 Nov;297(2):E263-E269.&#13;
	Bellosta R, Luzzani L, Natalini G, Pegorer MA, Attisani L, Cossu LG, Ferrandina C, Fossati A, Conti E, Bush RL, Piffaretti G. Acute limb ischemia in patients with COVID-19 pneumonia. J Vasc Surg. 2020; 72 (6):1864-1872.&#13;
	Kashi M, Jacquin A, Dakhil B, et al. Severe arterial thrombosis associated with Covid-19 infection. Thromb Res. 2020; 192:75-77.&#13;
	Singh B, Aly R, Kaur P, Gupta S, Vasudev R, Virk HS, Shamoon F, Bikkina M. COVID-19 Infection and Arterial Thrombosis: Report of Three Cases. Ann Vasc Surg. 2021 Jan;70:314-317&#13;
	Perini P, Nabulsi B, Massoni CB, Azzarone M, Freyrie A. Acute limb ischaemia in two young, non-atherosclerotic patients with COVID-19. Lancet. 2020 May 16; 395(10236):1546.&#13;
	Putko RM, Bedrin MD, Clark DM, Piscoya AS, Dunn JC, Nesti LJ. SARS-CoV-2 and limb ischemia: A systematic review. J Clin Orthop Trauma. 2021;12(1):194-199.&#13;
	Sand;aacute;nchez JB, Cuipal Alcalde JD, Ramos Isidro R, Luna CZ, Cubas WS, Coaguila Charres A, Gutiand;eacute;rrez JE, Ochoa JD, Arias PF. Acute Limb Ischemia in a Peruvian Cohort Infected by COVID-19. Ann Vasc Surg. 2020 Dec 31:S0890-5096 (20) 31102-X.&#13;
	Lari E, Lari A, AlQinai S, Abdulrasoul M, AlSafran S, Ameer A, Al-Sabah S. Severe ischemic complications in Covid-19-A case series. Int J Surg Case Rep. 2020;75:131-135.&#13;
	Anwar S, Acharya S, Shabih S, Khabut A. Acute Limb Ischemia in COVID-19 Disease: A Mysterious Coagulopathy. Cureus. 2020;12 (7):e9167.&#13;
	Demir KK, Simard C, Lipes J, Yang SS. Life and Limb: a Case of COVID-19-Associated Multisystem Thrombosis and Review of the Literature. J Gen Intern Med. 2021 Jan 5:1–5.&#13;
	Topcu AC, Ariturk C, Yilmaz E. Acute limb ischemia in a COVID-19 patient. Thrombosis Update. 2021;2:100031.&#13;
	Warrior K, Chung PA, Ahmed N, Soult MC, Simpson KP. Acute Limb Ischemia Due to Arterial Thrombosis Associated With Coronavirus Disease 2019. Crit Care Explor. 2020 Jun; 2(6): e0140.&#13;
	Wengerter SP, Wengerter KR, Masoudpoor H, Sagarwala A, Karim O, Rao N, Gillen J, Choi HM, Bernik T, Schwartz ML. Acute aortoiliac and infrainguinal arterial thrombotic events in four patients diagnosed with the novel coronavirus 2019. J Vasc Surg Cases Innov Tech. 2020 Dec;6(4):698-702.&#13;
	Levolger S, Bokkers RPH, Wille J, Kropman RHJ, de Vries JPM. Arterial thrombotic complications in COVID-19 patients. J Vasc Surg Cases Innov Tech. 2020 Sep;6(3):454-459.&#13;
	Hasan SA, Haque A, Nazir F. Acute Limb Ischemia: A Rare Complication of COVID-19. Cureus. 2020 Nov 15;12(11):e11488.&#13;
	Schweblin C, Hachulla AL, Roffi M, Glauser F. Delayed manifestation of COVID-19 presenting as lower extremity multilevel arterial thrombosis: a case report. Eur Heart J Case Rep. 2020 Nov 19;4(6):1-4.&#13;
	Soares RA, Vedovello RS, Medeiros SCG, Nunes CZ, Sian CA, Jorge PDM. COVID-19 diagnosis in a patient with critical limb ischemia: complications and clinical outcomes. J Vasc Bras. 2020;19:e20200071.&#13;
	Etkin Y, Conway AM, Silpe J, et al. Acute Arterial Thromboembolism in Patients with COVID-19 in the New York City Area. Ann Vasc Surg 2021; 70:290.&#13;
	Indes JE, Koleilat I, Hatch AN, et al. Early experience with arterial thromboembolic complications in patients with COVID-19. J Vasc Surg. 2021;73(2):381-389.e1.&#13;
	Ilonzo N, Rao A, Safir S, Vouyouka A, Phair J, Baldwin M, Ting W, Soundararajan K, Han D, Tadros R, Marin M, Faries P. Acute thrombotic manifestations of coronavirus disease 2019 infection: Experience at a large New York City health care system. J Vasc Surg. 2020 Sep 1:S0741-5214(20)31922-4.&#13;
	Thompson O, Pierce D, Whang D, et al. Acute limb ischemia as sole initial manifestation of SARS-CoV-2 infection. J Vasc Surg Cases Innov Tech 2020; 6:511.&#13;
	Kaur P, Posimreddy S, Singh B, et al. COVID-19 Presenting as Acute Limb Ischaemia. Eur J Case Rep Intern Med 2020; 7:001724.&#13;
	Essa RA and Ahmed SK. Case Report: Acute lower limb ischemia in a recovered COVID-19 patient [version 1; peer review: awaiting peer review]. F1000Research 2020, 9:1253.&#13;
	Veerasuri S, Kulkarni SR, Wilson WR, Paravastu SCV. Bilateral Acute Lower Limb Ischemia Secondary to COVID-19. Vasc Endovascular Surg 2021; 55:196.&#13;
	Galanis N, Stavraka C, Agathangelidis F, Petsatodis E, Giankoulof C, Givissis P. Coagulopathy in COVID-19 infection: a case of acute upper limb ischemia. J Surg Case Rep. 2020 Jul 2;2020(6):rjaa204.&#13;
	Hanif M, Ali MJ, Haider MA, et al. Acute Upper Limb Ischemia Due To Arterial Thrombosis in a Mild COVID-19 Patient: A Case Report. Cureus 2020; 12:e10349.&#13;
	Shao T, In-Bok Lee C, Jabori S, Rey J, Duran ER, Kang N. Acute upper limb ischemia as the first manifestation in a patient with COVID-19. J Vasc Surg Cases Innov Tech. 2020 Dec;6(4):674-677.&#13;
	Schultz K, Wolf JM. Digital Ischemia in COVID-19 Patients: Case Report. J Hand Surg Am 2020; 45:518.&#13;
	Giacomelli E, Dorigo W, Fargion A, et al. Acute Thrombosis of an Aortic Prosthetic Graft in a Patient with Severe COVID-19-Related Pneumonia. Ann Vasc Surg 2020; 66:8.&#13;
	Varga Z, Flammer AJ, Steiger P, et al. Endothelial cell infection and endotheliitis in COVID-19. Lancet 2020;395: 1417e8.&#13;
	Colling ME, Kanthi Y. COVID-19-associated coagulopathy: An exploration of mechanisms. Vasc Med 2020; 25:471.&#13;
	Fan BE, Chia YW, Sum CLL, et al. Global haemostatic tests in rapid diagnosis and management of COVID-19 associated coagulopathy in acute limb ischaemia. J Thromb Thrombolysis 2020; 50:292&#13;
	Terpos E, Ntanasis-Stathopoulos I, Elalamy I, et al. Hematological findings and complications of COVID-19. Am J Hematol 2020; 95:834.&#13;
	Creager MA, Kaufman JA, Conte MS. Clinical practice. Acute limb ischemia. N Engl J Med 2012; 366:2198.&#13;
	Mycroft?West C, Su D, Elli S, et al. The 2019 coronavirus (SARS?CoV?2) surface protein (Spike) S1 receptor binding domain undergoes conformational change upon heparin binding. bioRxiv. 2020. doi: https://doi.org/10.1101/2020.04.29.068486.&#13;
	Beun R, Kusadasi N, Sikma M, et al. Thromboembolic events and apparent heparin resistance in patients infected with SARS-CoV-2. Int J Lab Hematol 2020;42:19e20.&#13;
	Baccellieri D, Bilman V, Apruzzi L, et al. A Case of Covid-19 Patient with Acute Limb Ischemia and Heparin Resistance. Ann Vasc Surg 2020; 68:88.&#13;
	Lewis CT, Dayal R, Sundaram V, Chhaya V. Revascularization Outcomes in COVID-19 Patients With Acute Limb Ischemia. J Vasc Surg. 2020;72(5):e374.&#13;
	Dand;#39;Oria M, Mills JL Sr, Cohnert T, et al. The "Vascular Surgery COVID-19 Collaborative" (VASCC). Eur J Vasc Endovasc Surg 2020; 60:489.&#13;
	Vidali S, Morosetti D, Cossu E, et al. D-dimer as an indicator of prognosis in SARS-CoV-2 infection: a systematic review. ERJ Open Res. 2020; 6:00260.&#13;
	Tang N, Li D,Wang X, et al. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. J Thromb Haemost 2020;18:844e7.</References>