Acute Limb Ischemia in COVID-19 Patients: A Single University Center Experience

Abstract

IntroductionSevere acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is currently known to lead to high rates of thrombotic complications. Of those, acute limb ischemia (ALI) was most frequently reported. Several case reports or case series had already described high mortality and amputation rates. The purpose of our study was to highlight the epidemiological, clinical, and management characteristics of coronavirus disease 2019 (COVID-19)-related ALI patients. MethodsThis was a monocentric, observational, and retrospective study. Records of all patients ≥18 years of age admitted with ALI and a confirmed diagnosis of COVID-19 infection between March 2020 and December 2021 were retrospectively examined. Data collected included demographics, co-morbidities, biological findings, COVID-19 pneumonia and ALI severity, anatomical location of arterial thromboembolism, treatments, and outcomes. ResultsDuring the study period, 22 patients with ALI infected with COVID-19 were evaluated. The median age was 67 years (45-88) and 18 (81.8%) were men. The main comorbidities were diabetes mellitus (36.4%), smoking (22.7%), and arterial hypertension (18.2%). All 22 patients were already diagnosed positive for SARS-CoV-2. The median duration between COVID-19 diagnosis and ALI symptom onset was six days (1-13 days). The computed tomography (CT) extent of pulmonary lesions was assessed according to the French Society of Chest Imaging. The ischemic syndrome was classified on Rutherford Stage IIA (30.4%) and IIB (43.5%). Regarding thrombotic locations, ALI had occurred essentially in the lower limbs (95% vs. 5%). A revascularization procedure was performed in 14 patients (63.6%) of the patients, and primary amputation was unavoidable in five patients (22.7%). Three patients (13.6%) did not undergo operative management, two because of their hemodynamic instability and one rejected surgery. We performed 23 revascularization procedures for 14 patients and three primary amputations. Thromboembolectomy (TE) was the technique of choice (92.8%). Below-the-knee (BTK) femoropopliteal bypass was performed in one patient. Selective tibial vessel thrombectomy was performed in four patients (28.6%). The mortality rate was 27.3%. Among survivors, two secondary amputations were needed with a limb salvage rate of 68.2%. ConclusionBy the apparent end of the pandemic, our study further supports the increased risk of ALI in COVID-19positive patients. Moreover, the results affirm the unfavorable outcomes highly impacted by rethrombosis, reinterventions, and consequently high rates of amputations and mortality.

A rare complication of acute lower limb ischemia post coronavirus disease 2019 infection in a healthy pediatric patient: case report

“…However, in a case report in Greece, the authors attempted to combine thrombolytic therapy with recombinant tissue plasminogen activator (rt-PA) and immunosuppressive therapy with IL-6 (tocilizumab) in a patient who was admitted with acute respiratory failure secondary to COVID-19 pneumonia, who later developed ALI in his lower limb digits. However, after starting the management patient showed poor prognosis and had major amputations in which he died due to respiratory failure [ 11 ]. The patient, wherein we used a combination of Enoxaparin, tocilizumab, and pulse steroid therapy, later showed complete resolution of symptoms in all previously involved digits [ 12 ].…”

The Impact of COVID-19 on Amputation and Mortality Rates in Patients with Acute Limb Ischemia: A Systematic Review and Meta-Analysis

“…The systematic review of the literature collected 11 different studies, for a total of 15,803 patients. Seven of these were retrospective studies [22,[27][28][29][30][31][32], three were prospective [33][34][35], while one [36] was a prospective study that included a comparison group formed by a retrospectively collected cohort.…”

“…Five studies [27,29,31,32,36] included as a comparison group a cohort of pre-COVID patients, who had been treated for ALI in the period between 2017 and 2019. Four further studies, [22,30,33,34] considered for comparisons negative patients treated concurrently as COVID-19-positive patients. The study by Goldman et al [27] included both a pre-COVID-19 group and patients who tested SARS-CoV-2 negative during the period from January 2020 to April 2020.…”

“…A high range of geographical heterogeneity was found throughout the studies, as they were conducted across five different continents (five in North America [22,[27][28][29]32], three in Europe [34][35][36], one in South America [33], one in Africa [30], and one in Asia [31]).…”

“…More than one half of the studies (7 out of 11) included patients admitted to single specialized/tertiary vascular or trauma medical centers [27][28][29][30]33,35,36], whereas in one study, data were collected from a network of four regional vascular surgery hubs [34]. In three further studies, data were extracted from electronic medical records from networks of healthcare organizations [22,32] or obtained from medical records of two tertiary vascular centers [31].…”