Management of COVID-19-related Arterial Thrombosis Leading to Acute Limb-threatening Ischemia

  1. Omer Ehsan
  2. Mohammad Iqbal Khan
  3. Muhammad Waqas Raza

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Abstract

Objective

Examine the occurrence and clinical outcomes of arterial thrombosis leading to limb-threatening ischemia in patients with coronavirus-2019 (COVID-19).

Study design

Prospective, descriptive case series.

Patients and Methods

Forty-four patients with COVID-19 infection presenting with critical limb ischemia were managed between March 2020 and December 2020. The patients were divided into three groups based on the mode of presentation: 1) those who had been admitted; 2) those presenting in the emergency department; and 3) those presenting to vascular clinics. Clinical evidence suggesting limb ischemia was evaluated with computerized tomographic angiogram. Vascular care was designed according to the need of individual patients, through anticoagulation, revascularization by thrombo-embolectomy, or bypass grafting and amputation.

Results

Ten major amputations and 4 deaths (all in patients admitted) occurred among the 44 patients (9.1%). Most patients (32/44) were males, mean age was 55, and limb ischemia occurred among patients as young as 29. The initial period of ischemia was often not appreciated by patients and physicians. Critical limb ischemia was often not correlated with the severity of COVD symptoms: of 17 patients who presented through the emergency room with limb-threatening ischemia, 10 (58.9%) were asymptomatic for respiratory and general symptoms. Comorbidities were common among all 3 patient groups (26/44; 59%). Anticoagulants did not consistently prevent thromboembolic events since all admitted patients were receiving low molecular weight heparin. The rate of revascularization was lower in this population than in the general population with similar limb ischemia.

Conclusion

Acute limb ischemia in patients with COVID-19 is a vascular emergency that can result in limb loss and even death. The severity of respiratory infection and other symptoms of COVID often are not consistent with the severity and level of vascular involvement. Timely recognition and tailored intervention is needed to save limbs in this population.

What this paper adds to existing knowledge

COVID-19 infection predisposes to arterial and venous thrombosis, but data on arterial thrombosis are sparse. This report describes a series of 44 COVID-19 patients who had arterial thrombosis causing limb-threatening ischemia. Most noteworthy characteristics of the condition are its severity (10 major amputations and 4 deaths); subtle initial expression of the ischemia, which may lead to delayed diagnosis; severity and level of vascular involvement poorly correlated with respiratory symptoms; nearly 60% frequency of comorbidities (diabetes, hypertension, and ischemic heart disease); and low rate of successful revascularization compared with that of usual thromboembolic limb ischemia.

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  1. ScreenIT

    SciScore for 10.1101/2021.03.20.21252888: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    Institutional Review Board Statementnot detected.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.
    Sex as a biological variablenot detected.

    Table 2: Resources

    No key resources detected.

    Results from OddPub: We did not detect open data. We also did not detect open code. Researchers are encouraged to share open data when possible (see Nature blog).

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    This study has limitations. It is a single-site study of modest-size population; studies of larger populations in multiple sites are needed to assess its general applicability. It is a retrospective study, albeit of prospective patient accrual, so it has inherent potential for biases.

    Results from TrialIdentifier: No clinical trial numbers were referenced.

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a protocol registration statement.

    About SciScore

    SciScore is an automated tool that is designed to assist expert reviewers by finding and presenting formulaic information scattered throughout a paper in a standard, easy to digest format. SciScore checks for the presence and correctness of RRIDs (research resource identifiers), and for rigor criteria such as sex and investigator blinding. For details on the theoretical underpinning of rigor criteria and the tools shown here, including references cited, please follow this link.

  2. Version published to 10.1101/2021.03.20.21252888 on medRxiv