Outcomes of acute limb ischemia in COVID-19.

OBJECTIVE: The inflammatory cascade caused by severe acute respiratory syndrome coronavirus 2 infection may result in arterial thrombosis and acute limb ischemia (ALI) with devastating consequences. The aims of this study were to compare outcomes of ALI in the lower extremities in patients with and without coronavirus disease 2019 (COVID-19), and to determine if ALI development in the context of COVID-19 portends a worse prognosis compared with COVID-19 without ALI. METHODS: Queries were built on TriNetX, a federated network of health care organizations across the United States that provides de-identified patient data. International Classification of Diseases, 10th revision diagnostic codes were used to identify patients with acute limb ischemia of the lower extremities and COVID-19. The study timeframe was defined as January 20, 2020 to May 20, 2021. Statistical analyses, including propensity-score matching, were done through TriNetX's internal software. Outcomes looked at are rates of mortality, stroke, myocardial infarction, major adverse limb events, re-intervention, respiratory failure, sepsis, mental health complications, and acute renal failure. Baseline cohort characteristics were also collected. RESULTS: Patients with ALI with COVID-19 (ALI C19+; n = 526) were significantly less likely than patients with ALI without COVID-19 (ALI; n = 14,131) to have baseline comorbidities, including nicotine dependence (18% vs 33%; P < .0001). In contrast, ALI C19+ patients had significantly more comorbidities than hospitalized patients with COVID-19 without ALI (n = 275,903), including nicotine dependence (18% vs 10%; P < .0001). After propensity matching was performed, ALI C19+ patients had significantly higher rates of mortality (24.9% vs 9.2%; P < .0001), major adverse limb events (5.8% vs 2.9%; P = .0223), and acute renal failure (22.2% vs 14.9%; P = .0025) than patients with ALI. Compared with hospitalized patients with COVID-19 without ALI, ALI C19+ patients had higher propensity-matched rates of respiratory failure and being placed on assisted ventilation (32.9% vs 27%; P = .0369), sepsis (16.9% vs 12.2%; P = .0288), acute renal failure (22.1% vs 14.6%; P = .0019), and mortality (24.7% vs 14.4%; P < .0001). CONCLUSIONS: Patients who developed ALI following COVID-19 present with significantly different demographics and comorbidities from those who develop ALI without COVID-19. After controlling for these variables, higher rates of major adverse limb events, acute renal failure, and mortality in patients with ALI with COVID-19 suggest that not only may COVID-19 precipitate ALI, but it may also exacerbate ALI sequelae. Furthermore, development of ALI in COVID-19 portends worse prognosis compared with patients with COVID-19 without ALI.

Warfarin versus direct oral anticoagulants for patients needing distal deep vein thrombosis treatment.

OBJECTIVE: Great interest exists in standardizing the anticoagulant choice for patients requiring treatment of distal deep vein thrombosis (DDVT). In the present multicenter, retrospective cohort study, we evaluated the outcomes of patients with DDVT who had been treated with warfarin vs direct oral anticoagulants (DOACs; ie, rivaroxaban, apixaban, edoxaban, dabigatran). METHODS: Queries were built for the TriNetX database (TriNetX LLC, Cambridge, Mass), a federated network of healthcare organizations across the United States that provides de-identified patient data through aggregated counts and statistical summaries. International Classification of Diseases, 10th revision, diagnostic codes were used to identify eligible patients. Data from January 1, 2013 to January 1, 2020 were reviewed. Statistical analyses, including propensity matching, were performed using TriNetX's internal software. The inclusion criterion was treatment with either warfarin or a DOAC started within the first 24 hours of diagnosis of an isolated thrombosis of the following veins: anterior tibial, posterior tibial, peroneal, or calf muscular veins. The exclusion criteria were a history of an adverse reaction to anticoagulant agents, SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) infection, thrombophilia, mechanical heart valve, chronic proximal DVT (PDVT) and/or DDVT, and 6-month history of the following: acute PDVT, pulmonary embolism (PE), or anticoagulant usage. The outcomes measured included the incidence of mortality, PE, PDVT, stroke, myocardial infarction, and major bleeding within 6 months after initiating anticoagulation therapy. RESULTS: In a cohort of 6509 patients, 1570 were treated with warfarin and 4939 were treated with a DOAC drug. After propensity matching for age, sex, ethnicity, and comorbidities, the DOAC cohort had a significantly lower incidence of PE (1.795% vs 3.590%; P = .0020) and major bleeding (7.949% vs 10.513%; P = .0134). Differences in the incidence of mortality, PDVT, myocardial infarction, and stroke were not statistically significant. CONCLUSIONS: Before the present study, no strong evidence was available to suggest an optimal treatment modality for DDVT requiring anticoagulation therapy. The data from the present study suggest that patients receiving DOACs for the treatment of DDVT will have significantly lower rates of progression to PE and a lower incidence of major bleeding compared with patients receiving warfarin. This suggests that DOACs are superior to warfarin for treatment of DDVT.