A review of acute limb ischemia in COVID-positive patients

Aortic floating thrombus in patients with COVID-19: a report of eight cases

BACKGROUND

Thromboembolic events of COVID-19 are due to hyperinflammatory process associated with hypercoagulable state. The aim of the study was to determine characteristics and clinical outcomes of patients with COVID-19 who presented with aortic thrombus.

METHODS

We retrospectively conducted a single-center, descriptive study over a period of 1 year and 7 months, between June 2021 and December 2022, involving eight patients with documented SARS-CoV-2 infection associated with aortic thrombus revealed by acute limb ischemia.

RESULTS

The mean age of patients was 67 years with a median of 64, 5 ± 14. Of the eight included patients, six were men and two were women. Aortic thrombus was diagnosed in all cases. Six patients developed one episode of acute limb ischemia and one patient had recurrent upper and lower ischemia despite full anticoagulation whereas one patient had distal embolization with palpable pulses. In six patients, the thrombi were located in descending and abdominal aorta, while two patients presented with ascending aorta floating thrombus. Seven patients required urgent revascularization whereas medical treatment was recommended for one patient. The primary outcomes were successful in five cases, one patient had to be amputated above elbow, whereas two patients died due to a rapid deterioration of respiratory condition.

CONCLUSION

Aortic thrombosis is a rare clinical presentation in SARS-CoV-2 infection but with potentially fatal embolic complication. Physicians should maintain a high degree of clinical suspicion to diagnose thromboembolic consequences of SARS-CoV-2 infection for timely management and avoiding morbidities like ischemic stroke and major amputations.

Acute Limb Ischemia Management and Complications: From Catheter-Directed Thrombolysis to Long-Term Follow-up

Acute limb ischemia (ALI) is a vascular emergency that needs to be diagnosed and treated quickly to prevent permanent tissue damage and amputation. Catheter-directed thrombolysis is a possible treatment option for mild to moderate ALI, with improved results from endovascular procedures and thrombolytic drugs. However, patients receiving thrombolysis may experience higher rates of distal embolization, serious bleeding events, and stroke than those undergoing surgery. The review article emphasizes the need for postoperative and extended management of ALI patients, including monitoring for compartment syndrome, managing reperfusion damage, and reducing changeable cardiovascular risk factors such as lipid-lowering therapy, diabetes management, and smoking cessation. Complications that can arise from thrombolytic therapy are also discussed, including hemorrhagic complications, minor bleeding, and reperfusion damage, with recommendations to monitor patients closely during treatment and discontinue therapy immediately if any abnormalities are detected. Follow-up evaluations for patients, including Doppler ultrasound, ankle brachial index, pulse volume recordings, and laboratory tests, are recommended to ensure the best possible outcome for patients with ALI.

The results of thrombectomy from the arteries of the lower extremities in patients infected with SARS-CoV-2 Omicron variant with different severity of respiratory failure

GOAL

Analysis of the results of thrombectomy from the arteries of the lower extremities in patients with COVID-19 against the background of different severity of respiratory failure.

MATERIALS AND METHODS

This retrospective, cohort, comparative study for the period from 05/01/2022 to 20/07/2022 included 305 patients with acute thrombosis of the arteries of the lower extremities against the background of the course of COVID-19 (SARS-CoV-2 Omicron variant). Depending on the type of oxygen support, 3 groups of patients were formed: group 1 (n = 168) - oxygen insufflation through nasal cannulas; group 2 (n = 92) - non-invasive lung ventilation; and group 3 (n = 45) - artificial lung ventilation.

RESULTS

Myocardial infarction and ischemic stroke were not detected in the total sample. The highest number of deaths (group 1: 5.3%, n = 9; group 2: 72.8%, n = 67; group 3: 100%, n = 45; p < 0.0001), rethrombosis (group 1 : 18.4%, n = 31; group 2: 69.5%, n = 64; group 3: 91.1%, n = 41; p < 0.0001), and limb amputations (group 1: 9.5%, n = 16; group 2: 56.5%, n = 52; group 3: 91.1%, n = 41; p < 0.0001) was recorded in group 3 (ventilated) patients.

CONCLUSION

In patients infected with COVID-19 and on artificial lung ventilation, a more aggressive course of the disease is noted, expressed in an increase in laboratory parameters (C-reactive protein, ferritin, interleukin-6, and D-dimer) of the degree of pneumonia (CT-4 in overwhelming number) and localization of thrombosis of the arteries of the lower extremities, mainly in the tibial arteries.

Paradoxical Embolism Is an Unusual Etiology of Acute Limb Ischemia in Patients Suffering from COVID-19 Infection

Acute limb ischemia (ALI) is a large contributor to morbidity and mortality annually and can be managed either operatively or medically. ALI is most often caused by arterial embolism or in situ thrombosis and treatment is often dependent upon the severity. Anticoagulation is considered standard of care and first line therapy. However, more severe cases of ALI require surgical intervention.Paradoxical emboli are a rare and potentially under-appreciated cause of ALI. They arise when venous emboli, from a variety of sources, traverse a patent foramen ovale (PFO) to enter the arterial system, compromising blood flow to the affected end organ. In most cases, they can only be proven if the thrombus is identified as it crosses the cardiac defect, at which point it is an indication for surgery requiring PFO closure, management for the ischemia itself, and possible intervention for the embolism.In this report, we identify and discuss management of a series of cases where ALI was precipitated by PFOs that were discovered in the context of a pulmonary emboli that developed into paradoxical emboli. All patients had a confirmed diagnosis of COVID-19 which has been associated with a state of hypercoagulability and subsequent thrombus formation.

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

BACKGROUND

Coronavirus Disease 2019 (COVID-19) is a novel respiratory disease that first emerged in 2019. Patients infected with this disease present with a myriad of symptoms. Limb ischemia and hypercoagulability are complications identified in adults. COVID-19-related vasculitis is a known but seldom reported complication in pediatric patients, and the treatment approach is still not well established.

CASE PRESENTATION

We report the case of a healthy four-year-old female with a history of COVID-19 who developed acute lower limb ischemia. This was initially treated as a case of acute snake envenomation by administering snake antivenom with no improvement. She eventually developed lower limb acrocyanosis with an inability to ambulate. The patient was started on interleukin-6 receptor inhibitors (tocilizumab), anticoagulants, and pulse steroid therapy. The patient had complete resolution with the loss of only one toe.

CONCLUSION

Identification of thromboembolic complications in pediatric patients with no comorbidities and a history of COVID-19 can be difficult. Early recognition and treatment have a major impact on morbidity and can increase the likelihood of limb salvage.

COVID-associated acute limb ischemia during the Delta surge and the effect of vaccines

OBJECTIVE

Hypercoagulability is common in severe acute respiratory syndrome coronavirus 2 and has been associated with arterial thrombosis leading to acute limb ischemia (ALI). Our objective was to determine the outcomes of concurrent coronavirus disease 2019 (COVID-19) infection and ALI, particularly during the Delta variant surge and the impact of vaccination status.

METHODS

A retrospective review was performed of patients treated at a single health care system between March 2020 and December 2021 for ALI and recent (<14 days) COVID-19 infection or who developed ALI during hospitalization for the same disease. Patients were grouped by year as well as by pre and post Delta variant emergence in 2021 based on the World Health Organization timeline (January to May vs June to December). Baseline demographics, imaging, interventions, and outcomes were evaluated. A control cohort of all patients with ALI requiring surgical intervention for a 2-year period prior to the pandemic was used for comparison. Primary outcomes were in-hospital mortality and amputation-free survival. Kaplan-Meier survival and Cox proportional hazards analysis were performed.

RESULTS

Forty acutely ischemic limbs were identified in 36 patients with COVID-19, the majority during the Delta surge (52.8%) and after the wide availability of vaccines. The rate of COVID-19-associated ALI, although low overall, nearly doubled during the Delta surge (0.37% vs 0.20%; P = .09). Intervention (open or endovascular revascularization vs primary amputation) was performed on 31 limbs in 28 individuals, with the remaining eight treated with systemic anti-coagulation. Postoperative mortality was 48%, and overall mortality was 50%. Major amputation following revascularization was significantly higher with COVID-19 ALI (25% vs 3%; P = .006) compared with the pre-pandemic group. Thirty-day amputation-free survival was significantly lower (log-rank P < .001). COVID-19 infection (adjusted hazard ratio, 6.2; P < .001) and age (hazard ratio, 1.1; P = .006) were associated with 30-day amputation in multivariate analysis. Severity of COVID-19 infection, defined as vasopressor usage, was not associated with post-revascularization amputation. There was a higher incidence of re-thrombosis in the latter half of 2021 with the Delta surge, as reintervention for recurrent ischemia of the same limb was more common than our previous experience (21% vs 0%; P = .55). COVID-19-associated limb ischemia occurred almost exclusively in non-vaccinated patients (92%).

CONCLUSIONS

ALI observed with Delta appears more resistant to standard therapy. Unvaccinated status correlated highly with ALI occurrence in the setting of COVID-19 infection. Information of limb loss as a COVID-19 complication among non-vaccinated patients may help to increase compliance.

Endothelial dysfunction in COVID-19: an overview of evidence, biomarkers, mechanisms and potential therapies

The fight against coronavirus disease 2019 (COVID-19) caused by SARS-CoV-2 infection is still raging. However, the pathophysiology of acute and post-acute manifestations of COVID-19 (long COVID-19) is understudied. Endothelial cells are sentinels lining the innermost layer of blood vessel that gatekeep micro- and macro-vascular health by sensing pathogen/danger signals and secreting vasoactive molecules. SARS-CoV-2 infection primarily affects the pulmonary system, but accumulating evidence suggests that it also affects the pan-vasculature in the extrapulmonary systems by directly (via virus infection) or indirectly (via cytokine storm), causing endothelial dysfunction (endotheliitis, endothelialitis and endotheliopathy) and multi-organ injury. Mounting evidence suggests that SARS-CoV-2 infection leads to multiple instances of endothelial dysfunction, including reduced nitric oxide (NO) bioavailability, oxidative stress, endothelial injury, glycocalyx/barrier disruption, hyperpermeability, inflammation/leukocyte adhesion, senescence, endothelial-to-mesenchymal transition (EndoMT), hypercoagulability, thrombosis and many others. Thus, COVID-19 is deemed as a (micro)vascular and endothelial disease. Of translational relevance, several candidate drugs which are endothelial protective have been shown to improve clinical manifestations of COVID-19 patients. The purpose of this review is to provide a latest summary of biomarkers associated with endothelial cell activation in COVID-19 and offer mechanistic insights into the molecular basis of endothelial activation/dysfunction in macro- and micro-vasculature of COVID-19 patients. We envisage further development of cellular models and suitable animal models mimicking endothelial dysfunction aspect of COVID-19 being able to accelerate the discovery of new drugs targeting endothelial dysfunction in pan-vasculature from COVID-19 patients.

Unexpected arterial thrombosis and acute limb ischemia in a young male patient with COVID-19: A case report

Introduction

The spread of severe acute respiratory syndrome coronavirus 2 has resulted in coronavirus disease 2019 (COVID-19) pandemic, raising significant concerns. COVID-19 can lead to thrombotic complications such as acute limb ischemia (ALI). In patients with COVID-19, thrombotic complications may increase the risk of morbidity and mortality.

Presentation of case

We report the case of a 37-year-old man who presented with a 2 weeks history of right foot pain, toes blackish discoloration, and numbness. He tested positive for COVID-19 10 days prior to his presentation. Computed tomography angiography (CTA) of the lower limbs revealed near-complete occlusion of the right popliteal artery with single-vessel posterior tibial artery runoff. The patient was brought to a hybrid operating room, and diagnostic angiography confirmed the diagnosis. He underwent popliteal artery thromboembolectomy and intraoperative thrombolysis through a posterior approach. A completion angiography demonstrated a patent popliteal artery with a 2-vessels patency to the foot. His postoperative recovery was uneventful. After surgery, the popliteal, anterior tibial, and posterior tibial arteries were all palpable. The patient was discharged home on antiplatelet therapy with frequent postoperative follow-ups during the last 1 year in our outpatient clinic.

Discussion

The frequency of ALI has reduced worldwide, and the hypercoagulable condition remains an infrequent cause of limb ischemia. Patients with COVID-19 have a 35%-45% thromboembolic complication rate. In many studies, the virus launches a second attack between 7 and 14 days after symptom onset, possibly causing hypercoagulability. If conservative treatment fails, various surgical methods, including thromboembolectomy, thrombolysis, and thrombosuction, can be performed to treat ALI.

Conclusion

In mild ALI symptoms, unfractionated heparin can be used with vigilant follow-up. Open and endovascular procedures are currently used to treat patients with acute limb ischemia, and technological advancements continue to make interventions easier and safer.

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

Introduction Severe 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. Methods This 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. Results During 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%. Conclusion By the apparent end of the pandemic, our study further supports the increased risk of ALI in COVID-19-positive patients. Moreover, the results affirm the unfavorable outcomes highly impacted by rethrombosis, reinterventions, and consequently high rates of amputations and mortality.

Analysis of Presentation and Outcomes in Acute Limb Ischemia Patients During COVID-19 State of Emergency

BACKGROUND

During the COVID-19 pandemic, cardiovascular patients were found to be presenting to hospitals with myocardial infarctions and cerebrovascular accidents at progressed disease states. We noticed a parallel in acute limb ischemia (ALI) patients presenting during Massachusetts' COVID-19 State of Emergency declaration. We question whether patients developed a hesitancy to seek medical attention at hospitals due to fear of COVID-19. Our objective was to compare acuity of ALI, interventions, and limb survival in patients presenting before, during, and after a state of emergency.

METHODS

Four timeframes were set to compare patients presenting peri-2020 COVID-19 State of Emergency and patients presenting during a pre-pandemic era at a tertiary, academic institution. A reference period from 2019, Pre-State of Emergency period, State of Emergency period, and Post-State of Emergency period were designated. Patient characteristics, interventions, and outcomes data were collected. Unpaired t-test, ANOVA, and Chi-square statistical analyses were used.

RESULTS

A total of 95 patients presenting with ALI were identified. Compared to Reference group, state of emergency group had more patients presenting with Rutherford Class III, 12.9% vs 35%, and less patient presenting with Class I, 45.1% vs 0%, P = .02. State of emergency group had more delayed presentations with ≥6 hours after symptom onset, 45% vs 85%, P = .01. Above-knee amputations were performed in 20% of patients during state of emergency and 31.6% for Post-State of Emergency, vs 6.5% in the Reference group; P = .03. There was no difference in intensive care unit admission, length of stay, or mortality between patients from different groups.

CONCLUSION

During a state of emergency, ALI patients were noted to present later from symptom onset, have greater disease severity, and more likely to undergo amputations. We suspect delay in presentation and limb lost to be attributed to reluctance to seek immediate medical attention.

Management of Acute Limb Ischaemia Due to COVID-19 Induced Arterial Thrombosis: A Multi-Centre Indian Experience

Objective: To determine the outcomes following various surgical and medical treatments of Coronavirus disease 2019 (COVID-19) induced acute limb ischaemia.

Methods: A retrospective study of patients presenting with COVID induced arterial ischaemia in three hospitals from Southern India during the months of May 2020 to August 2021 was undertaken. These patients were managed by either thrombectomy, primary bypass, thrombolysis, anticoagulation or primary amputation based on the stage of ischaemia and the severity of COVID.

Results: A total of 67 limbs in 59 patients were analysed. The average time to intervention was 15 days. Upper limb involvement was seen in 16 and lower limb in 51 limbs. Of the 67 limbs, 39 (58.2%) were treated by open surgical revascularisation, 5 (7.4%) by catheter directed lysis, 17 (25.3%) were managed conservatively and 6 (8.9%) underwent primary amputation. Successful revascularisation could be carried out in 88.6% of patients. A limb salvage rate of 80.6% was achieved in these patients with a re-intervention rate of 13.6%. Major amputation rate was 14.92% and mortality was 13.56%.

Conclusion: Limb ischaemia after COVID can be safely managed by open thrombectomy or bypass. Similar rates of limb salvage as in non-COVID acute limb ischaemia can be obtained.

Unexpected arterial thrombosis and acute limb ischemia in COVID-19 patients. Results from the Ibero-Latin American acute arterial thrombosis registry in COVID-19: (ARTICO-19)

OBJECTIVE

Few studies have focused on arterial thrombosis and acute limb ischemia in COVID-19. This international registry intended to study the spectrum of clinical characteristics, therapeutic trends, and outcomes in a cohort of Ibero-Latin American patients with arterial thrombosis or acute limb ischemia and COVID-19.

METHODS

Data were retrospectively obtained from 21 centers in 9 countries. Patients with proven COVID-19 and asymptomatic or symptomatic arterial thrombosis were included. COVID-19 diagnosis was established by RT-PCR assay or IgM serology plus suggestive clinical/radiographical findings. We recorded and analyzed variables related to demography, clinical presentation, therapeutic trends, and outcomes.

RESULTS

Eighty one patients were included in the registry. In 38.3%, acute limb ischemia symptoms were the first manifestation of COVID-19. Non-surgical management was more frequent in severe cases than surgical interventions, 11.1% vs. 88.9%, respectively (p = 0.004). Amputation rates were similar between all COVID severity groups (p = 0.807). Treatment was classified as non-surgical, open surgical, and endovascular treatment. Further analysis revealed an equal frequency of major leg amputation between treatment groups and increased mortality in patients with non-surgical management. However, multivariate regression analysis showed that treatment choices are associated with disease severity, with significant non-surgical treatment in critical patients; thus, mortality is related to the severity and confounds treatment analysis.

CONCLUSION

Arterial thrombosis can be the initial symptom of a patient presenting with COVID-19. Physicians and health workers should potentially suspect COVID-19 in acute ischemia cases without a known risk factor or embolic cause. More experimental and clinical research is required to understand the complex phenomenon of arterial COVID-19 induced coagulopathy fully.

Distal arteriovenous fistula to preserve patency in COVID-19-associated acute limb ischemia

The purpose of this study was to report our institutional experience with patients with COVID-19 who developed acute limb ischemia during hospitalization and to determine the characteristics and clinical outcomes. Between March 2020 and January 2021, we treated 3 patients who were COVID-19-positive and developed acute limb ischemia after they received thromboprophylaxis. We performed an embolectomy by exposing the popliteal artery below the knee to treat an occlusion of the popliteal and tibial arteries. An infusion of unfractionated heparin was initiated immediately after surgery, maintaining a partial thromboplastin time ratio > 2.5 times the normal value and transferred the patients to the intensive care unit. However, after these patients developed recurrent acute limb ischemia in the same leg, we decided to perform an embolectomy of popliteal and tibial arteries at the ankle and created an arteriovenous fistula (AVF) with tibial veins using polypropylene 7-0. The first patient died from pneumonia after 3 weeks in the intensive care unit; at that time, the foot was viable with triphasic flow in the distal posterior tibial artery and the AVF was patent. The second and third patients are doing well, they can walk without any problems, and the tibial arteries and AFV were patent on duplex ultrasound after 6 months. The AVF allowed part of the flow of tibial arteries to divert into the small veins of the foot that have a low resistance to maintain patency of tibial vessels, despite a hypercoagulable state and extensive thrombotic microangiopathy in patients with COVID-19.

Mechanical rotational thrombectomy in long femoropopliteal artery and stent occlusion in COVID-19 patient: Case report

Introduction

Coronavirus disease-19 (COVID-19) has been increasingly associated with thromboembolic complications. COVID-19 infection has a thrombogenic potential for stents. Herein, we report a case of stent thrombosis in diabetic obese patient COVID-19 positive where was previously released a Multilayer Flow Modulator stent (MFM) for large popliteal aneurysm.

Case report

A 78-year-old male was referred to our hospital for fever and acute pain in the left leg. At history, the same patient had endovascular procedure for a large symptomatic popliteal aneurysm, treated through release of three MFM. The pulmonary CT scan showed COVID-19 infection with confirm of rhino-laryngeal swab. Duplex ultrasound and CT-angiography showed complete thrombosis of stents. The treatment consisted of mechanical thrombectomy using an 8Fr catheter Rotarex plus release of Vibahn stent-graft.

Discussion

COVID-19 patients can present arterial occlusion. In literature are not reported cases about thrombosis peripheral stent. Minimally invasive approaches in redo-procedure reduce risk of infection. Rotarex device was used in revascularization of acute and subacute iliac and femoropopliteal arteries. The goal is to have a debulking, to avoid an incomplete deployment of stent-graft. In our precedent experience, MFM and stent-graft to treatment of popliteal aneurism were safe. It is important to monitor these patients for early identification of failure and rapprochement. In this case, the COVID-19 infection was determinant in promoting thrombosis.

Conclusions

COVID-19 increases risk of thrombosis stent. In our experience debulking through Rotarex and stenting, were decisive factors for revascularization and limb salvage.