Acute limb ischemia and antithrombotic therapy in COVID-19 patients

Galyfos G, et al. Acute limb ischemia among patients with COVID-19 infection. J Vasc Surg. 2022 Jan;75(1):326-342. doi: 10.1016/j.jvs.2021.07.222. Epub 2021 Aug 12.

Results: In total, 34 studies (19 case reports and 15 case series/cohort studies) including a total of 540 patients (199 patients were eligible for analysis) were evaluated. All studies were published in 2020. Mean age of patients was 61.6 years (range, 39-84 years; data from 32 studies) and 78.4% of patients were of male gender (data from 32 studies). There was a low incidence of comorbidities: arterial hypertension, 49% (29 studies); diabetes mellitus, 29.6% (29 studies); dyslipidemia, 20.5% (27 studies); chronic obstructive pulmonary disease, 8.5% (26 studies); coronary disease, 8.3% (26 studies); and chronic renal disease, 7.6% (28 studies). Medical treatment was selected as first-line treatment for 41.8% of cases. Pooled mortality rate among 34 studies reached 31.4% (95% confidence interval [CI], 25.4%%-37.7%). Pooled amputation rate among 34 studies reached 23.2% (95% CI, 17.3%-29.7%). Pooled clinical improvement rate among 28 studies reached 66.6% (95% CI, 55.4%%-76.9%). Pooled reoperation rate among 29 studies reached 10.5% (95% CI, 5.7%%-16.7%). Medical treatment was associated with a higher death risk compared with any intervention (odds ratio, 4.04; 95% CI, 1.075-15.197; P = .045) although amputation risk was not different between the two strategies (odds ratio, 0.977; 95% CI, 0.070-13.600; P = .986) (data from 31 studies).

Conclusions: SARS-CoV-2 infection is associated with a high risk for thrombotic complications, including ALI. COVID-associated ALI presents in patients with a low incidence of comorbidities, and it is associated with a high mortality and amputation risk. Conservative treatment seems to have a higher mortality risk compared with any intervention, although amputation risk is similar.

Attisani L, et al. COVID-19 and acute limb ischemia: a systematic review. J Cardiovasc Surg (Torino). 2021 Dec;62(6):542-547. Free full-text.

Evidence synthesis: We selected 36 articles with a total of 194 patients. Most patients were male (80%) with a median age of 60 years old. The treatment most used was thromboembolectomy (31% of all surgical interventions). A total of 32 patients (19%) were not submitted to revascularization due to critical status. The rate of technical success was low (68%), and mortality rate was high (35%).

Conclusions: This review confirms that SARS-CoV-2 is associated with a high risk of ALI. Further studies are needed to investigate the association and elucidate potential mechanisms, which may include a hypercoagulable state and hyperactivation of the immune response. Furthermore, management of ALI is not standardized and depends on patient condition and extension of the thrombosed segment. ALI in COVID-19 patients is associated with high risk of failure of revascularization and perioperative mortality.

Ilonzo N, et al. A review of acute limb ischemia in COVID-positive patients. Semin Vasc Surg. 2021 Jun;34(2):8-12. doi: 10.1053/j.semvascsurg.2021.04.004. Epub 2021 May 20.

“In studies that reported Rutherford classification at presentation, most patients presented with Rutherford IIA or IIB ALI. In fact, 28% to 77% presented with Rutherford IIA and 17% to 75% presented with Rutherford IIB [2,25,29]. It is important to note that few patients will also present with a thrombotic event, despite having been on therapeutic anticoagulation. In one study, 19.1% of patients had been on anticoagulation before their arterial thrombotic event [25]. There is also no clear correlation between timing of the COVID infection and the arterial thrombotic event. Obviously, it is difficult to estimate this in asymptomatic patients, but many hospitalized patients will develop ALI during their hospitalization and it varies between 6.6 and 15.77 days after their admission for other COVID-related symptoms [30,31].”

NIH Treatment Guidelines: The COVID-19 Treatment Guidelines Panel’s Statement on Anticoagulation in Hospitalized Patients With COVID-19. Updated January 5, 2022.

American Society of Hematology: COVID-19 and VTE/Anticoagulation: Frequently Asked Questions. Updated January 24, 2022.

More articles on ALI in COVID-19 patients.

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