Published online Nov 20, 2022. doi: 10.5662/wjm.v12.i6.476
Peer-review started: April 15, 2022
First decision: August 1, 2022
Revised: September 1, 2022
Accepted: November 4, 2022
Article in press: November 4, 2022
Published online: November 20, 2022
It is well-known that coronavirus disease 2019 (COVID-19) infection is associated with hypercoagulability among affected patients. This has become known as COVID-19 induced coagulopathy (CIC). This study investigated CIC-related thrombotic complications through a systematic review and meta-analysis of the existing literature.
There is paucity of data describing the relationship between COVID-19 infection and thrombotic complications necessitating the need for surgical intervention. Intestinal ischemia and acute limb ischemia (ALI) are amongst the most common thrombotic events due to COVID-19 that required operative management. An overall postoperative mortality of 30% was found in those who underwent operative procedures for thrombotic complications, with most deaths occurring in those with bowel ischemia. Physicians should be aware that despite thromboprophylaxis, severe thrombotic complications can still occur in this patient population, however, surgical intervention results in relatively low mortality apart from cases of ischemic bowel resection.
Main, overarching objective was to conduct a systematic review to find the currently published medical literature describing surgical interventions necessitated by COVID-19 thrombotic complications. We achieved this objective and identified intestinal ischemia and ALI as the most common thrombotic events necessitating surgical intervention.
The current systematic review was performed using an algorithmic approach to review all the currently available articles in the English medical literature on surgical interventions necessitated by COVID-19 thrombotic complications using the preferred reporting items for systematic reviews and meta-analysis principles. A comprehensive literature search in the “PubMed”, “Scopus”, “Google Scholar” top 100 results, and archives of Plastic and Reconstructive Surgery was performed by two authors (Reynolds A and Edoigiawerie S) on January 4, 2022, using the key words “COVID-19” AND “surgery” AND “thromboembolism” AND “complication” as well as associated terms. The search string was generated and the records which were not relevant were excluded. Articles published prior to 2019 were excluded as being prior to the COVID-19 pandemic and therefore not relevant to complications associated with COVID-19 infection. Titles, abstracts, and full-text articles were assessed for eligibility and inclusion. On initial and secondary search, papers in review, commentary, or letter format or those without accessible full-text articles were excluded. Finally, results were further reviewed and refined to focus on articles that featured surgical interventions that were necessitated by COVID-19 thrombotic complications. For completion of the search, the references of the selected publications were additionally screened with the previously mentioned inclusion criteria.
The database search resulted in the final inclusion of 22 retrospective studies, after application of the inclusion/exclusion criteria. Of the included studies, 17 were single case reports, 3 were case series and 2 were cross sectional cohort studies. All studies were retrospective in nature. Twelve of the reported studies were conducted in the United States of America, with the remaining studies originating from Italy, Turkey, Pakistan, France, Serbia, and Germany. All cases reported in our study were laboratory confirmed severe acute respiratory syndrome coronavirus 2 positive. A total of 70 cases involving surgical intervention were isolated from the 22 studies included in this review.
Physicians should be aware that despite thromboprophylaxis, severe thrombotic complications can still occur in this patient population, however, surgical intervention results in relatively low mortality apart from cases of ischemic bowel resection.
Future directions could focus on how to prevent thrombotic complications and mitigate mortality among patients at risk for ALI and bowel ischemia in particular.