Outcomes of Surgical Revascularization for Acute Limb Ischemia in COVID-19 Patients Comparing to Noninfected Cohort: A Single-Center Observational Prospective Study.

BACKGROUND: The purpose of the study was to compare the clinical presentation, management, and outcomes of surgical revascularization for acute limb ischemia (ALI) in 2 groups of patients-with and without SARS-CoV-2 infection. METHODS: During the 2 years (01.01.2020-31.12.2021) all consecutive patients diagnosed with ALI and treated with urgent revascularization were prospectively enrolled. Based on the results of polymerase chain reaction swab for SARS-CoV-2 infection patients were allocated to group A-infected or group B-noninfected. Demographic characteristics, clinical, imaging, laboratory data, and details of treatment were collected prospectively. The composite endpoint of major amputation and/or death at 30 days after surgery was defined as main study outcome. The postoperative ankle-brachial index value, reinterventions, complications, and length of hospital stay were considered as secondary outcomes. RESULTS: Overall, 130 patients (139 limbs with ALI) were analyzed-21 patients (23 limbs) in group A and 109 patients (116 limbs) in group B. The anatomical site of arterial occlusion, duration, and severity of ischemia did not differ significantly between the groups. Patients with COVID-19 had significantly shorter time from ALI onset till administration of the first dose of anticoagulant: 8 (2.5-24) hr vs. 15.7 (6-72) hr in group B, P = 0.02. Vascular imaging was performed before intervention only in 5 (23.8%) infected patients compared to 78 (71.5%) patients in group B, P < 0.001. The main outcome was registered in 38 (29.2%) patients, significantly more frequent in infected cohort: 12 (57.1%) patients in group A versus 26 (23.8%) in group B, P = 0.003. Difference was preponderantly caused by high mortality in group A-9 (42.8%) patients, compared to 17 (15.5%) patients in group B, P = 0.01. The difference in the rate of limb loss was not statistically significant: 4 (17.3%) limbs were amputated in COVID-19 patients and 12 (10.3%) limbs-in noninfected patients (P = 0.3). Combination of ALI and COVID-19 resulted in increased 30-day mortality-risk ratio (RR) 2.7 (95% confidence interval [CI]: 1.42-5.31), P = 0.002, but did not lead to significantly higher amputation rate-RR 1.6 (95% CI: 0.59-4.75), P = 0.32. In group A initial admission of the patient in the intensive care unit was an independent risk factor for amputation/death. Excepting systemic complications which were more frequently registered among COVID-19 patients: 7 (33%) cases vs. 14 (12.8%) in group B, P = 0.04; no differences in other secondary outcomes were observed between the groups. CONCLUSIONS: Study demonstrates the significant negative impact of COVID-19 upon the 30-day amputation-free survival in patients undergoing urgent surgical revascularization for ALI. The difference in outcome is influenced by higher rate of mortality among infected patients, rather than by the rate of limb loss. Severity of COVID-19, namely requirement of intensive care, mostly determines the outcome of ALI treatment.

Acute limb ischemia.

Acute limb ischemia (ALI) is an emergency situation requiring rapid diagnosis and treatment. Although the traditional treating strategy for ALI includes open surgery, novel endovascular techniques have been introduced during the last decade. Additionally, many new cases of ALI have been reported due to infection by the SARS-CoV-2 virus. The aim of this study was to present an updated overview of characteristics, diagnosis, and current treating strategies of patients with ALI.

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.

Impact of the COVID-19 Lockdown Strategy on Vascular Surgery Practice: More Major Amputations than Usual.

BACKGROUND: The aim of this study is to investigate the impact of the coronavirus disease 2019 (COVID-19) lockdown period on the number and type of vascular procedures performed in the operating theater. METHODS: A total of 38 patients who underwent 46 vascular procedures during the lockdown period of March 16th until April 30th, 2020, were included. The control groups consisted of 29 patients in 2019 and 54 patients in 2018 who underwent 36 and 66 vascular procedures, respectively, in the same time period. Data were analyzed using SPSS Statistics. RESULTS: Our study shows that the lockdown during the COVID-19 pandemic resulted in a significant increase in the number of major amputations (42% in 2020 vs. 18% and 15% in 2019 and 2020, respectively; P-value 0.019). Furthermore, we observed a statistically significant difference in the degree of tissue loss as categorized by the Rutherford classification (P-value 0.007). During the lockdown period, patients presented with more extensive ischemic damage when than previous years. We observed no difference in vascular surgical care for patients with an aortic aneurysm. CONCLUSIONS: Measurements taken during the lockdown period have a significant effect on non-COVID-19 vascular patient care, which leads to an increased severe morbidity. In the future, policy makers should be aware of the impact of their measurements on vulnerable patient groups such as those with peripheral arterial occlusive disease. For these patients, medical care should be easily accessible and adequate.