Acute limb ischemia in patients with COVID-19 pneumonia

Abstract

Objective: The aim of our study was to determine the incidence, characteristics, and clinical outcomes of patients with the novel coronavirus (COVID-19) infection who had presented with and been treated for acute limb ischemia (ALI) during the 2020 coronavirus pandemic.

Methods: We performed a single-center, observational cohort study. The data from all patients who had tested positive for COVID-19 and had presented with ALI requiring urgent operative treatment were collected in a prospectively maintained database. For the present series, successful revascularization of the treated arterial segment was defined as the absence of early (<30 days) re-occlusion or major amputation or death within 24 hours. The primary outcomes were successful revascularization, early (≤30 days) and late (≥30 days) survival, postoperative (≤30 days) complications, and limb salvage.

Results: We evaluated the data from 20 patients with ALI who were positive for COVID-19. For the period from January to March, the incidence rate of patients presenting with ALI in 2020 was significantly greater than that for the same months in 2019 (23 of 141 [16.3%] vs 3 of 163 [1.8%]; P < .001)]. Of the 20 included patients, 18 were men (90%) and two were women (10%). Their mean age was 75 ± 9 years (range, 62-95 years). All 20 patients already had a diagnosis of COVID-19 pneumonia. Operative treatment was performed in 17 patients (85%). Revascularization was successful in 12 of the 17 (70.6%). Although successful revascularization was not significantly associated with the postoperative use of intravenous heparin (64.7% vs 83.3%; P = .622), no patient who had received intravenous heparin required reintervention. Of the 20 patients, eight (40%) had died in the hospital. The patients who had died were significantly older (81 ± 10 years vs 71 ± 5 years; P = .008). The use of continuous postoperative systemic heparin infusion was significantly associated with survival (0% vs 57.1%; P = .042).

Conclusions: In our preliminary experience, the incidence of ALI has significantly increased during the COVID-19 pandemic in the Italian Lombardy region. Successful revascularization was lower than expected, which we believed was due to a virus-related hypercoagulable state. The use of prolonged systemic heparin might improve surgical treatment efficacy, limb salvage, and overall survival.

Keywords: Acute limb ischemia; COVID-19.

Fig 1

Preoperative computed tomography scan of a 66-year-old man with COVID-19-related pneumonia and acute limb ischemia. Transverse and coronal thin-section scans show extensive ground-glass opacities of both lungs.

Fig 2

Preoperative computed tomography angiography with volume rendering 3-dimensional reconstruction (A) showing the presence of intraluminal thrombus (B) at the infrarenal aorta (white arrow), total occlusion of the popliteal segment (white dotted arrows), and the absence of tibial vessels, bilaterally. Final completion angiogram showing the morphological aspect of “desert foot” after large amount of thrombus removal for femoral-popliteal-tibial occlusion that required selective thrombectomy of all tibial vessels bilaterally.

Fig 3

Thrombus (A and B) specimen after aortoiliac-femoropopliteal thrombectomy and bilateral selective tibial artery thrombectomy.

Fig 4

Estimated projection of patients with acute limb ischemia (ALI) in 2020 compared with those treated in 2019 at the same center.