Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 9  |  Issue : 2  |  Page : 178-180

Clinical Profile and Outcomes in Surgically Treated COVID-19 Patients Presenting with Acute Limb Ischemia


1 Department of Vascular Surgery, Shree Krishna Hospital, Bhaikaka University, Karamsad, Anand, Gujarat, India
2 Department of General Surgery, Shree Krishna Hospital, Bhaikaka University, Karamsad, Anand, Gujarat, India

Date of Submission31-Dec-2021
Date of Decision01-Apr-2022
Date of Acceptance08-Apr-2022
Date of Web Publication13-Jun-2022

Correspondence Address:
Varin Rangwala
Department of General Surgery, Shree Krishna Hospital, Bhaikaka University, Karamsad, Anand, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_137_21

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  Abstract 


Background: Acute limb ischemia (ALI) refers to a sudden decrease in blood flow to the limb which threatens its viability. Such a sudden event of decreased or absent arterial supply to the limb causes ischemia and poor perfusion outcomes. The most common causes of ALI include embolism and thrombosis. Others include acute on chronic peripheral arterial occlusive disease or major trauma. It is well known to us that COVID-19 is a hypercoagulable state. In this prothrombotic state, patients can also present with ALI, with clinical features of pain, paresthesia, pulselessness, pallor, poikilothermia, and paralysis of the affected limb. Such patients rapidly progress to severe stages of limb ischemia that need immediate treatment to save the limb. Thus, our study aims to revisit the clinical features and outcomes of procedures performed on such patients. Materials and Methods: This is a single-center, retrospective study. COVID patients with ALI who underwent any surgical procedure, from February 2021 to July 2021, were identified from the surgical operation theater's list of the hospital. Detailed information regarding these patients was obtained from the digital software of the hospital. Detailed computed tomography angiography findings were also obtained from the radiology department. A required statistical study was done. Results: Nineteen COVID patients presenting with ALI and requiring surgical treatment were identified during the study period of 6 months. A complete study of their clinical presentations, surgical procedures performed and the outcomes, is done. The study shows that the most common site affected was the lower limb (95%) with occlusion occurring mainly in the popliteal artery, i.e., the lower limb artery. Conclusion: Recognition of limb ischemia at an early stage, considering it as a symptom or complication of COVID-19, may allow for early and prompt diagnosis and treatment of this condition.

Keywords: Acute limb ischemia, COVID-19, surgical interventions, vascular surgery


How to cite this article:
Patel J, Rangwala V, Thakkar Z, Bhatt R. Clinical Profile and Outcomes in Surgically Treated COVID-19 Patients Presenting with Acute Limb Ischemia. Indian J Vasc Endovasc Surg 2022;9:178-80

How to cite this URL:
Patel J, Rangwala V, Thakkar Z, Bhatt R. Clinical Profile and Outcomes in Surgically Treated COVID-19 Patients Presenting with Acute Limb Ischemia. Indian J Vasc Endovasc Surg [serial online] 2022 [cited 2022 Aug 11];9:178-80. Available from: https://www.indjvascsurg.org/text.asp?2022/9/2/178/347256




  Introduction Top


COVID-19 infection mainly affects the respiratory system of the human body, leading to severe acute respiratory syndrome.[1] However, it has also been seen that a proportion of patients do progress to a systemic disease due to the varied pathological alterations in the body.[2] COVID-19 often leads to multiple organ dysfunctions through commonly a direct infection or rarely due to its parainfectious complications resulting in substantial mortality.[1],[2],[3],[4],[5] One of the major pathological changes in COVID infection includes hypercoagulable states as evidenced by an increase in biomarkers levels such as D-dimer, fibrinogen, and prothrombin time prolongation.[6],[7] Such a state causes systemic coagulopathies affecting the lungs, heart, brain, mesentery, kidneys, limbs, etc.

Acute limb ischemia (ALI) due to arterial thrombosis is a known emergency in the department of vascular surgery. Multiple etiological factors are known to cause arterial occlusions, one of which is the hypercoagulable state in COVID. Computed tomography angiography (CTA) findings reveal arterial occlusion in upper or lower extremities.[8] Treating ALI in COVID-19 patients seems to be challenging due to its increased chances of progression to gangrenous states and worsening mortality rates.[9],[10] Our hospital, being a tertiary care center, received COVID-19 patients presenting with varied complications which also included ALI. Even though patients were given prophylactic anticoagulation, hypercoagulable states and their known complications were encountered time and again.[9] There were an increasing number of COVID patients being admitted to intensive care unit (ICU) and wards from the beginning of the year 2020, peaking in April and May 2020. The department of vascular surgery of our hospital had to also deal with peripheral arterial occlusive disease cases in COVID-19 patients progressing to emergency vascular procedures and surgeries.

Thus, the study in this article aims to identify the surgically treated COVID-19 causing ALI patients, studying their clinical profiles, the surgical procedures conducted, and its outcomes, to aid refined management of such cases in the future.


  Materials and Methods Top


Source of data

COVID-positive patients with ALI who underwent any surgical procedure, from February 2021 to July 2021, were identified from the surgical operation theater's list of the hospital. Detailed information regarding these patients was obtained from the digital software of our hospital. Detailed CTA findings were also obtained from the radiology department. A required statistical study was done. Informed consent is waived off as it is a retrospective study. Patient confidentiality is maintained during the study.

Inclusion criteria

Patients with clinically or radiologically confirmed ALI with RTPCR positive or HRCT confirmed COVID-19 patients were included in the study.

Exclusion criteria

PostCOVID-19 patients were excluded from the study.


  Results Top


The study compromised a total of 19 patients, out of which 15 were male and 4 were female, and the mean age was 59.6 years + 10.4 years. The mean number of days from onset of COVID symptoms to the first sign or symptom of ALI was 7.9 days + 4 days. Eighteen out of 19 patients had their lower limb affected with 1 having his upper limb. [Table 1] shows the arteries occluded in the patients under study. Most of them had their lower limb arteries involved. On the Rutherford classification [Table 2] of patients, 57.8% of patients belonged to Category 3. The tables below show the clinical picture of patients studied and procedures performed [Table 3].
Table 1: Artery involved in ALI patients

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Table 2: Rutherford classification in ALI patients

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Table 3: Surgical procedures performed on ALI patients

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Eleven patients were rendered disabled after undergoing amputation. Two of them could not survive even after the surgical interventions.


  Discussion Top


In our tertiary center, the incidence of ALI cases has been significantly increased over the years. COVID-19 is a multisystem disorder involving hematologic and cardiovascular. Despite using anticoagulation as prophylaxis, COVID-19 patients were not only at increased risk of ALI but also subsequent limb loss and mortality. Successful revascularization rates were lower probably due to a hypercoagulable state. The use of prolonged anticoagulation might improve outcomes, but major complications of the thrombolytic method are a disadvantage of it. Patients with higher cardiac and operative risk may benefit from alternative revascularization strategies. The results of this study are consistent with the growing evidence of increased risk and frequency of thromboembolic events in patients with COVID-19. Although venous thromboembolic events are well recognized in COVID-19, this study demonstrated a risk of arterial thrombosis in severe acute respiratory distress syndrome due to COVID-19 infection. Importantly, a higher incidence of arterial thrombosis was seen in patients with COVID-19 presenting with ALI.[1] Thrombosis of distal vessels leads to critical limb ischemia ultimately resulting in threatened limb loss. There may be an association between acute thrombosis or embolism or chronic occlusion in the limb due to atherosclerotic plaque and calcification, but we were not able to analyze the same due to a lack of documented data. In this analysis, a significantly increased rate of limb amputation (57.8%) and death (10.22%) was found in patients with COVID-19. This can also be attributed to severe COVID-19 disease, which was associated with cytokine storm, pulmonary embolism, and hypercoagulability causing the development of thrombosis despite patients taking therapeutic anticoagulation. In addition, due to the pandemic situation, people often neglect their symptoms and present late at the health-care setup. The availability of beds in the ICU may indirectly contribute to this outcome. Thrombosis may set in, but the awareness that limb ischemia may be associated with COVID-19 should prompt evaluation and treatment accordingly. One of the limitations of the study was that we could not get a larger study sample size and the severity of respiratory symptoms at the time of ALI presentation could not be particularly documented and assessed, but all the patients under study were ICU hospitalized for moderate-to-severe COVID-19 as per the AIIMS/WHO guidelines, i.e., at least requiring oxygen support due to inadequate blood oxygen saturation levels. The incidence of death and amputation is significantly more common in patients with COVID-19, especially if systemic or respiratory coexists.[9],[10]


  Conclusion Top


Recognition of limb ischemia at an early stage, considering it as a symptom or complication of COVID-19, may allow for early and prompt diagnosis and treatment of this condition. ALI in COVID-19 has a higher incidence of morbidity and mortality, resulting in an increased burden on health-care resources in the form of financial and social support.

Adequate use of personal protective equipment, especially certified respiratory face masks and vaccinations, serves as an effective measure to protect against the spread of COVID infection including among medical and paramedical professionals. This also reduces health-care/hospital-associated COVID infections, reducing the overall disease burden. As new pandemic waves and coronavirus mutations emerge, adequate self-protection along with vaccinations is the only way to reduce the community spread of COVID infections and thus its complications.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Goldman IA, Ye K, Scheinfeld MH. Lower-extremity arterial thrombosis associated with COVID-19 is characterized by greater thrombus burden and increased rate of amputation and death. Radiology 2020;297:E263-9.  Back to cited text no. 1
    
2.
Melissano G, Mascia D, Baccellieri D, Kahlberg A, Bertoglio L, Rinaldi E, et al. Pattern of vascular disease in Lombardy, Italy, during the first month of the COVID-19 outbreak. J Vasc Surg 2020;72:4-5.  Back to cited text no. 2
    
3.
Needham EJ, Chou SH, Coles AJ, Menon DK. Neurological implications of COVID-19 infections. Neurocrit Care 2020;32:667-71.  Back to cited text no. 3
    
4.
Puelles VG, Lütgehetmann M, Lindenmeyer MT, Sperhake JP, Wong MN, Allweiss L, et al. Multiorgan and renal tropism of SARS-CoV-2. N Engl J Med 2020;383:590-2.  Back to cited text no. 4
    
5.
Aghagoli G, Gallo Marin B, Soliman LB, Sellke FW. Cardiac involvement in COVID-19 patients: Risk factors, predictors, and complications: A review. J Card Surg 2020;35:1302-5.  Back to cited text no. 5
    
6.
Rostami M, Mansouritorghabeh H. D-dimer level in COVID-19 infection: A systematic review. Expert Rev Hematol 2020;13:1265-75.  Back to cited text no. 6
    
7.
Iba T, Levy JH, Levi M, Thachil J. Coagulopathy in COVID-19. J Thromb Haemost 2020;18:2103-9.  Back to cited text no. 7
    
8.
Ogawa M, Doo FX, Somwaru AS, Roudenko A, Kamath A, Friedman B. Peripheral arterial occlusion due to COVID-19: CT angiography findings of nine patients. Clin Imaging 2021;73:43-7.  Back to cited text no. 8
    
9.
Abou-Ismail MY, Diamond A, Kapoor S, Arafah Y, Nayak L. The hypercoagulable state in COVID-19: Incidence, pathophysiology, and management. Thromb Res 2020;194:101-15.  Back to cited text no. 9
    
10.
Maatman TK, Jalali F, Feizpour C, Douglas A 2nd, McGuire SP, Kinnaman G, et al. Routine venous thromboembolism prophylaxis may be inadequate in the hypercoagulable state of severe coronavirus disease 2019. Crit Care Med 2020;48:e783-90.  Back to cited text no. 10
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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