COVID-19 and Acute Limb Ischemia: A Systematic Review

Pramod Theetha Kariyanna¹, Apoorva Jayarangaiah², Anahat Kaur², Amog Jayarangaiah³, Sushruth Das³, Ruchi Yadav⁴, Neema Jayachamarajapura Onkaramurthy⁵, Ashkan Tadayoni⁶, Moro O. Salifu⁶ and Isabel M. McFarlane^6,

¹Division of Interventional Cardiology, Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Morningside/Beth Israel Hospitals, New York City, NY-10025, U.S.A.

²Division of Hematology and Oncology, Department of Internal Medicine, Albert Einstein College of medicine/ Jacobi Medical Center, Bronx, N.Y.-10461, U.S.A.

³Trinity School of Medicine, 925 Woodstock Road, Roswell, GA 30075, U.S.A.

⁴Department of Internal Medicine, Brookdale University Hospital Medical Center, Brooklyn, NY 11212, U.S.A.

⁵Department of Internal Medicine, NYC Health and Hospitals/Harlem Hospital Center, New York 10037, U.S.A

⁶Department of Internal Medicine, State University of New York, Downstate Health Sciences University, Brooklyn, NY 11203, U.S.A.

Cite this paper

Pramod Theetha Kariyanna, Apoorva Jayarangaiah, Anahat Kaur, Amog Jayarangaiah, Sushruth Das, Ruchi Yadav, Neema Jayachamarajapura Onkaramurthy, Ashkan Tadayoni, Moro O. Salifu and Isabel M. McFarlane. COVID-19 and Acute Limb Ischemia: A Systematic Review. American Journal of Medical Case Reports. 2021; 9(6):312-317. doi: 10.12691/AJMCR-9-6-2

Abstract

The extraordinary prothrombotic manifestations of Coronavirus Disease-2019 (COVID-19), caused by severe acute respiratory syndrome CoV (SARS-CoV-2) virus, presenting as venous and arterial thrombosis have been reported in the literature. The incidence of arterial thrombosis is reported to be 4% in critically ill COVID-19 patients.. Arterial thrombosis in the setting of COVID-19 has been reported to occur in a multitude of organs leading to ischemic strokes, ST-segment elevation myocardial infarction, aortic thrombus and acute limb ischemia. Diffuse endothelial activation, along with aberrant immuno-thrombotic mechanisms have been implicated in the widespread thrombosis occurring in COVID-19 patients. We performed a literature review of 55 reported cases to delineate the clinical characteristics, management patterns and outcomes of patients with COVID-19 who developed complications of acute limb thrombosis and ischemia. Our systematic review revealed that acute limb ischemia had a male predominance, with either hypertension or diabetes mellitus as the most common underlying cardiovascular risk factors. Aortic thrombus was reported in 23.6% of the cases. The majority of the cases involved thrombosis in more than one limb, indicative of a diffuse thrombotic state. The most common artery affected was the left popliteal artery. Upper limb thrombosis occurred in 40% of the cases. Most of the cases (74.5%) were managed with urgent revascularization interventions and anticoagulation. Negative outcomes, including amputations (14.9%) and death (26.5%) occurred at a higher rate in this population, despite the use of standard management.

Keywords

Coronavirus Disease-2019 (COVID-19), severe acute respiratory syndrome CoV (SARS-CoV-2) virus, acute limb ischemia, immune-thrombosis

Copyright

This work is licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/

References

[1]	Miesbach, Wolfgang, and Michael Makris. “COVID-19: coagulopathy, risk of thrombosis, and the rationale for anticoagulation.” Clinical and Applied Thrombosis/Hemostasis 26 (2020): 1076029620938149.
[2]	Kariyanna, Pramod Theetha, et al. “A Systematic Review of COVID-19 and Myocarditis.” American journal of medical case reports 8.9 (2020): 299.
[3]	Varga, Zsuzsanna, et al. “Endothelial cell infection and endotheliitis in COVID-19.” The Lancet 395.10234 (2020): 1417-1418.
[4]	Alosaimi, R., A. Albajri, and R. M. Albalwi. “Acute Upper Limb Ischemia in a Patient with COVID-19 Pneumonia.” MedRead J Fam Med 1.4 (2020): 1015.
[5]	Anwar, Shamsuddin, et al. “Acute limb ischemia in COVID-19 disease: a mysterious coagulopathy.” Cureus 12.7 (2020).
[6]	Baccellieri, Domenico, et al. “A case of Covid-19 patient with acute limb ischemia and heparin resistance.” Annals of Vascular Surgery 68 (2020): 88-92.
[7]	Bhoriwal, Sandeep, et al. “Acute arterial thrombosis in a breast cancer survivor with coronavirus disease 2019 (COVID-19).” Surgery 168.5 (2020): e19-e20.
[8]	Cañas, E. Gonzalez, et al. “Acute peripheral arterial thrombosis in COVID‐19. Role of endothelial inflammation.” The British Journal of Surgery (2020).
[9]	Essa, Rawand Abdulrahman, and Sirwan Khalid Ahmed. “Case Report: Acute lower limb ischemia in a recovered COVID-19 patient.” F1000Research 9.1253 (2020): 1253.
[10]	Fahad, Ahmed Muhi, et al. “Case report: COVID-19 in a female patient who presented with acute lower limb ischemia.” F1000Research 9.778 (2020): 778.
[11]	Galanis, Nikiforos, et al. “Coagulopathy in COVID-19 infection: a case of acute upper limb ischemia.” Journal of surgical case reports 2020.6 (2020): rjaa204.
[12]	Del Giudice, P., et al. “Catastrophic acute bilateral lower limbs necrosis associated with COVID‐19 as a likely consequence of both vasculitis and coagulopathy.” Journal of the European Academy of Dermatology and Venereology 34.11 (2020): e679-e680.
[13]	Hanif, Muhammad, et al. “Acute Upper Limb Ischemia Due To Arterial Thrombosis in a Mild COVID-19 Patient: A Case Report.” Cureus 12.9 (2020).
[14]	Kaur, Parminder, et al. “COVID-19 presenting as acute limb ischaemia.” European journal of case reports in internal medicine 7.6 (2020).
[15]	Kaur, Parminder, et al. “Acute upper limb ischemia in a patient with COVID-19.” Hematology/oncology and stem cell therapy (2020).
[16]	Warrior, Krishnan, et al. “Acute Limb Ischemia Due to Arterial Thrombosis Associated With Coronavirus Disease 2019.” Critical Care Explorations 2.6 (2020).
[17]	Levolger, Stef, et al. “Arterial thrombotic complications in COVID-19 patients.” Journal of Vascular Surgery Cases and Innovative Techniques 6.3 (2020): 454-459.
[18]	Maurera, Annabella H., et al. “Acute Limb Ischemia in Minimally Symptomatic SARS-CoV-2 Infection.” Journal of Vascular and Interventional Radiology (2020).
[19]	Merz, Lauren E., et al. “Extensive Arterial Thrombosis in Covid-19.” American Journal of Cardiology 134 (2020): 148-149.
[20]	Mietto, Cristina, et al. “Acute lower limb ischemia as clinical presentation of COVID-19 infection.” Annals of Vascular Surgery 69 (2020): 80-84.
[21]	Muhammad, Kamel, et al. “Successful Catheter-directed thrombolysis for acute lower limb ischemia secondary to COVID-19 infection.” Annals of vascular surgery (2020).
[22]	Parekh et al. “Can COVID-19 cause limb ischemia? MeddyIzzyJournal (2020)
[23]	Patel, Priya, et al. “Systemic Thrombolysis as Initial Treatment of COVID-19 Associated Acute Aortoiliac and Lower Extremity Arterial Thrombosis.” Annals of Vascular Surgery 70 (2020): 297-301.
[24]	Perini, Paolo, et al. “Acute limb ischaemia in two young, non-atherosclerotic patients with COVID-19.” The Lancet 395.10236 (2020): 1546.
[25]	Qian, Song-Zan, and Jing-Ye Pan. “COVID-19 with limb ischemic necrosis.” Journal of cardiothoracic and vascular anesthesia 34.10 (2020): 2846-2847.
[26]	Schultz, Kathryn, and Jennifer Moriatis Wolf. “Digital ischemia in COVID-19 patients: case report.” The Journal of hand surgery 45.6 (2020): 518-522.
[27]	Singh, Balraj, et al. “COVID-19 Infection and Arterial Thrombosis: Report of three cases.” Annals of vascular surgery 70 (2020): 314-317.
[28]	Singh, Balraj, et al. “Covid-19 presenting as acute limb ischemia.” Cureus 12.7 (2020).
[29]	Vacirca, Andrea, et al. “Unheralded lower limb threatening ischemia in a COVID-19 patient.” International Journal of Infectious Diseases 96 (2020): 590-592.
[30]	Van Mecl, Amanda, et al. “A Case of COVID-19-Associated Acute Limb Ischemia.” Chest 158.4 (2020): A550.
[31]	Soares, Rafael de Athayde, et al. “COVID-19 diagnosis in a patient with critical limb ischemia: complications and clinical outcomes.” Jornal Vascular Brasileiro 19 (2020).
[32]	Veerasuri, Sowmya, et al. “Bilateral Acute Lower Limb Ischemia Secondary to COVID-19.” Vascular and Endovascular Surgery (2020): 1538574420954301.
[33]	Gubitosa, James C., Ahmed Ahmed Phoenix Xu, and Kathleen Pergament. “COVID-19-Associated Acute Limb Ischemia in a Patient on Therapeutic Anticoagulation.” Cureus 12.9 (2020).
[34]	Wengerter, Sean P., et al. “Acute aortoiliac and infrainguinal arterial thrombotic events in four patients diagnosed with the novel coronavirus 2019.” Journal of Vascular Surgery Cases and Innovative Techniques 6.4 (2020): 698-702.
[35]	Lari, Eisa, et al. “Severe ischemic complications in Covid-19—A case series.” International Journal of Surgery Case Reports 75 (2020): 131-135.
[36]	Singh, Gagandeep, et al. “COVID-19 related arterial coagulopathy.” Cureus 12.7 (2020).
[37]	Thompson, Owen, et al. “Acute limb ischemia as sole initial manifestation of SARS-CoV-2 infection.” Journal of Vascular Surgery Cases and Innovative Techniques 6.4 (2020): 511-513.
[38]	de Almeida Lima, Antonia Nayanne, et al. “<? covid19?> Images in Vascular Medicine: Acute peripheral artery occlusion and ischemic stroke in a patient with COVID-19.” Vascular Medicine 25.5 (2020): 482-483.
[39]	Ferguson, Katie, et al. “COVID-19 associated with extensive pulmonary arterial, intracardiac and peripheral arterial thrombosis.” BMJ Case Reports CP 13.8 (2020): e237460.
[40]	Renaud-Picard, Benjamin, et al. “Bilateral Acute Cardioembolic Limb Ischemia After Coronavirus Disease 2019 Pneumonia in a Lung Transplant Recipient: A Case Report.” Transplantation proceedings. Vol. 52. No. 9. Elsevier, 2020.
[41]	Kashi, Mahine, et al. “Severe arterial thrombosis associated with Covid-19 infection.” Thrombosis research 192 (2020): 75.
[42]	Tjendra, Youley, et al. “Predicting disease severity and outcome in COVID-19 patients: a review of multiple biomarkers.” Archives of pathology & laboratory medicine 144.12 (2020): 1465-1474.
[43]	Cheruiyot, Isaac, et al. “Arterial thrombosis in coronavirus disease 2019 (COVID-19) patients: A rapid systematic review.” Annals of vascular surgery (2020).
[44]	Klok, F. A., et al. “Incidence of thrombotic complications in critically ill ICU patients with COVID-19.” Thrombosis research (2020).
[45]	Kariyanna, Pramod Theetha, et al. “Apical Takotsubo cardiomyopathy in a COVID-19 patient presenting with stroke: a case report and pathophysiologic insights.” American journal of medical case reports 8.10 (2020): 350.
[46]	Kariyanna, Pramod Theetha, et al. “Pharmaco-invasive Therapy for STEMI in a Patient with COVID-19: A Case Report.” American journal of medical case reports 8.7 (2020): 192.
[47]	Jayarangaiah, Apoorva, et al. “COVID-19-associated coagulopathy: an exacerbated immunothrombosis response.” Clinical and Applied Thrombosis/Hemostasis 26 (2020): 1076029620943293.
[48]	Mancini, Ilaria, et al. “The ADAMTS13-von Willebrand factor axis in COVID-19 patients.” Journal of Thrombosis and Haemostasis (2020).
[49]	Holst, AG. Risk factors for venous thromboembolism results from the Copenhagen City Heart Study. J Cardiovasc Pharmacol. 1995; 25(suppl 2):S13–S19.
[50]	Fox, SE, Fox, SE, Akmatbekov, A, et al. Pulmonary and cardiac pathology in COVID-19: the first autopsy series from New Orleans. Chemrxiv Pre Print. 2020
[51]	Bellosta, Raffaello, et al. “Acute limb ischemia in patients with COVID-19 pneumonia.” Journal of vascular surgery 72.6 (2020): 1864-1872.