The Mysterious Risk of Arterial Thrombosis With COVID-19: A Case Series and Systematic Review of Acute Limb Ischaemia.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) generates a cytokine storm that predisposes patients to systemic complications including arterial thrombosis (AT) and acute limb ischaemia (ALI). This study reviews our understanding of the incidence and outcomes of patients with COVID-19 who develop AT. METHODS:  The case notes of all emergency patients with COVID-19 referred to the vascular services between March 2020 and March 2021 were reviewed. The study was undertaken to measure 30-day outcomes. Additionally, a literature search was undertaken according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using the following search terms: acute limb ischaemia OR arterial thrombosis OR thrombectomy OR embolectomy AND COVID-19. RESULTS: During March 2020 and March 2021, 60,000 people tested positive for COVID-19 in Norfolk. A total of 33 patients were referred to the vascular services, of which 15 had AT (estimated incidence of 0.03%). Of AT patients, 93% had ALI. Fourteen locations of AT were identified. Of ATs, 36% were infrainguinal. The 30-day mortality was 60%. Three patients underwent surgery: two embolectomies (one requiring subsequent below-knee amputation (BKA) and the other died) and one primary BKA requiring subsequent above-knee amputation. The 30-day amputation-free survival (AFS) rate was 29%. The literature search identified 361 studies prior to a thorough full-text review. Nine case series were included with more than 10 participants each. The incidence of AT was reported as high as 15%. In-hospital mortality was 40%, with a significant proportion undergoing amputation or palliative care. Approximately a third of patients undergoing revascularisation subsequently re-occluded. AFS remained as low as 25%. CONCLUSION:  The incidence of AT within the vascular surgery territory in COVID-19 patients is low; however, it is associated with poor 30-day AFS. A computed tomography angiography protocol including the entire major vessels may be indicated in COVID-19 patients.

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.

COVID-19-induced adult multisystem inflammatory syndrome and fatal acute limb ischaemia.

A case of coronavirus disease 2019 (COVID-19)-induced adult multisystem inflammatory syndrome (MIS) and fatal acute limb ischaemia is presented. Arterial thrombosis and MIS are reported as complications of COVID-19. This case further highlights that arterial thrombosis and MIS can occur in COVID-19.

Editor's Choice - Update of the European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia in Light of the COVID-19 Pandemic, Based on a Scoping Review of the Literature.

OBJECTIVE: To perform a scoping review of how patients with COVID-19 are affected by acute limb ischaemia (ALI) and evaluate the recommendations of the 2020 ESVS ALI Guidelines for these patients. METHODS: Research questions were defined, and a systematic literature search was performed following the PRISMA guidelines. Abstracts and unpublished literature were not included. The definition of ALI in this review is in accordance with the ESVS guidelines. RESULTS: Most identified papers were case reports or case series, although population based data and data from randomised controlled trials were also identified. In total, 114 unique and relevant papers were retrieved. Data were conflicting concerning whether the incidence of ALI increased, or remained unchanged, during the pandemic. Case reports and series reported ALI in patients who were younger and healthier than usual, with a greater proportion affecting the upper limb. Whether or not this is coincidental remains uncertain. The proportion of men/women affected seems unchanged. Most reported cases were in hospitalised patients with severe COVID-19. Patients with ALI as their first manifestation of COVID-19 were reported. Patients with ALI have a worse outcome if they have a simultaneous COVID-19 infection. High levels of D-dimer may predict the occurrence of arterial thromboembolic events in patients with COVID-19. Heparin resistance was observed. Anticoagulation should be given to hospitalised COVID-19 patients in prophylactic dosage. Most of the treatment recommendations from the ESVS Guidelines remained relevant, but the following were modified regarding patients with COVID-19 and ALI: 1) CTA imaging before revascularisation should include the entire aorta and iliac arteries; 2) there should be a high index of suspicion, early testing for COVID-19 infection and protective measures are advised; and 3) there should be preferential use of local or locoregional anaesthesia during revascularisation. CONCLUSION: Although the epidemiology of ALI has changed during the pandemic, the recommendations of the ESVS ALI Guidelines remain valid. The above mentioned minor modifications should be considered in patients with COVID-19 and ALI.

Regional Survey in Lombardy, Northern Italy, on Vascular Surgery Intervention Outcomes During The COVID-19 Pandemic.

OBJECTIVE: The characteristics and outcomes of patients undergoing vascular surgery hospitalised and managed in Lombardy are described with a comparison of patients tested positive for COVID-19 (CV19-pos) vs. those tested negative (CV19-neg). METHODS: This was a multicentre, retrospective, observational cohort study which involved all vascular surgery services in Lombardy, Northern Italy. Data were retrospectively merged into a combined dataset covering the nine weeks of the Italian COVID-19 pandemic phase 1 (8 March 2020 to 3 May 2020). The primary outcome was freedom from in hospital death, secondary outcomes were re-thrombosis rate after peripheral revascularisation, and freedom from post-operative complication. RESULTS: Among 674 patients managed during the outbreak, 659 (97.8%) were included in the final analysis: 121 (18.4%) were CV19-pos. CV19-pos status was associated with a higher rate of complications (OR 4.5; p < .001, 95% CI 2.64 - 7.84), and a higher rate of re-thrombosis after peripheral arterial revascularisation (OR 2.2; p = .004, 95% CI 1.29 - 3.88). In hospital mortality was higher in CV19-pos patients (24.8% vs. 5.6%; OR 5.4, p < .001;95% CI 2.86 - 8.92). Binary logistic regression analysis identified CV19-pos status (OR 7.6; p < .001, 95% CI 3.75 - 15.28) and age > 80 years (OR 3.2; p = .001, 95% CI 1.61 - 6.57) to be predictors of in hospital death. CONCLUSION: In this experience of the vascular surgery group of Lombardy, COVID-19 infection was a marker of poor outcomes in terms of mortality and post-operative complications for patients undergoing vascular surgery treatments.

Clinical spectrum of ischaemic arterial diseases associated with COVID-19: a series of four illustrative cases.

BACKGROUND: Severe coronavirus-induced disease 2019 (COVID-19) leads to acute respiratory distress syndrome with an increased risk of venous thrombo-embolic events. To a much lesser extent, arterial thrombo-embolic events have also been reported in this setting. CASE SUMMARY: Here, we describe four different cases of COVID-19 infection with ischaemic arterial events, such as a myocardial infarction with high thrombus load, ischaemic stroke on spontaneous thrombosis of the aortic valve, floating thrombus with mesenteric, splenic and renal infarction, and acute limb ischaemia. DISCUSSION: Cardiovascular risk factors such as hypertension, obesity, and diabetes are comorbidities most frequently found in patients with a severe COVID-19 infection and are associated with a higher death rate. Our goal is to provide an overview of the clinical spectrum of ischaemic arterial events that may either reveal or complicate COVID-19. Several suspected pathophysiological mechanisms could explain the association between cardiovascular events and COVID-19 (role of systemic inflammatory response syndrome, endothelial dysfunction, activation of coagulation cascade leading to a hypercoagulability state, virus-induced secondary antiphospholipid syndrome). We need additional studies of larger size, to estimate the incidence of these arterial events and to assess the efficacy of anticoagulation therapy.

Delayed manifestation of COVID-19 presenting as lower extremity multilevel arterial thrombosis: a case report.

BACKGROUND: Venous thrombo-embolic events have been described in hospitalized patients with coronavirus disease 2019 (COVID-19), suggesting the presence of coagulopathy induced by the viral infection. To date, only rare cases of arterial thrombosis related to COVID-19 have been reported. CASE SUMMARY: A 54-year-old patient with an influenza-like illness 15 days earlier, which resolved, and no known cardiovascular risk factor presented with acute right lower limb ischaemia. A computed tomography angiogram of the abdominal aorta and lower extremities showed, in the absence of vascular disease, a subocclusive thrombosis of the right common iliac artery and an occlusion of the right internal iliac, profunda femoral, and popliteal arteries. On the left side, the computed tomography angiogram demonstrated a non-occlusive thrombosis of the common femoral artery. The patient underwent emergency surgical thrombectomy as well as endovascular revascularization on the right side followed by therapeutic anticoagulation, with normalization of the limb perfusion. A nasopharyngeal swab for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by real-time reverse transcription-PCR (rRT-PCR) was negative three times. Haemostasis analysis showed a mild hyperfibrinogenaemia and a shortening of the activated partial thromboplastin time. An extensive screening for cardio-embolism was negative. As the thrombotic event was unexplained, antibody testing for SARS-CoV-2 was performed and the result was positive. DISCUSSION: Venous thrombosis and pulmonary embolisms have been observed in COVID-19. As in our case, the first reports on COVID-19-associated arterial thrombotic events have emerged. A better understanding of the coagulopathy in COVID-19 is essential to guide prevention and treatment of venous as well as arterial thrombo-embolic events.

Severe ischemic complications in Covid-19-A case series.

INTRODUCTION: Covid-19 has the propensity to result in a wide array of manifestations. Recently, thromboembolic complications of Covid-19 have been denoted in literature. We report 5 cases of Covid-19 positive patients with no significant comorbidities who developed 1st time episodes of either; acute limb ischemia or bowel ischemia. MATERIAL AND METHODS: This is a retrospective observational study analyzing the clinical characteristics and outcomes of five Covid-19 positive patients. Five patients aged 38-60 presented to our institution from 1st April to 1st June and were diagnosed with Covid-19 pneumonia, subsequently developing severe vascular complications. None of our patients included had any history of thromboembolism nor risk factors that could justify the presentations. PRESENTATION OF CASES: Patient 1; presented with bowel ischemia as a first presentation. Patient 2 and 3 developed unsalvageable lower limb ischemia secondary to partial to complete occlusion of infra-renal aorta. Patient 4 presented with acute upper limb ischemia due to complete occlusion of the axillary and brachial artery. Patient 5 developed bilateral lower limb unsalvageable ischemia secondary to aortic bifurcation occlusion. All patients tested Covid-19 positive upon admission, and received standard care. DISCUSSION AND CONCLUSION: The thromboembolic complications seen in our cases were devastating and resulted in significant mortality and morbidity. All vessels affected were medium-large vessels. None of our cases had any significant predisposing medical conditions or history of thromboembolic or ischemic events. A high index of suspicion is necessary when evaluating such patients regardless of thromboembolic history. Appropriate anticoagulation regimens are essential. Our cases add to the currently increasing severe thromboembolic complications of Covid-19.