Revascularization Outcomes of Acute Limb Ischemia in Patients With COVID-19

Acute limb ischemia (ALI) is one of the most catastrophic thrombotic manifestations of COVID-19 resulting in limb loss if not promptly treated. Our goal is to evaluate revascularization outcomes of ALI in patients with COVID-19 who underwent either open or endovascular treatment. The Vascular Surgery COVID-19 Collaborative started in March 2020 to assess hematological changes of COVID-19. We performed an interim data analysis on 46 patients with COVID-19 associated ALI submitted to the ALI module of the Vascular Surgery COVID-19 Collaborative REDcap database from 10 institutions in the United States. Among the 46 patients included in the analysis, the mean age was 62.2 (standard deviation [SD]: 9.51) years. The majority of patients were male (73.9%). A total of 67.4% were White, 13% were Hispanic, and 4.3% were Black. In total, 93.5% of patients met Rutherford’s criteria of ALI class 2 or 3. On average, patients developed ALI 12.2 (SD: 13.5) days after a positive COVID test. Revascularization was attempted using open thrombectomy in 50.0%, endovascular lysis or thrombectomy in 23.9%, and bypass in 2.2%, and revascularization was not attempted in 23.9% of the patients (Table). Revascularization was successful in 41.3% with symptom resolution and 15.2% with limb salvage but persistent symptoms; 2.2% had minor amputation, 4.3% ultimately had a major amputation, 4.3% required reoperation, and revascularization was unsuccessful in 10.9% of patients. The average length of hospital stay was 13.2 (SD: 13.3) days, the average intensive care unit (ICU) length of stay was 4.66 (SD: 6.85) days, and the average ventilation days was 12.3 (SD: 10.8) days. Overall, in-hospital mortality was 21.7%, 8.7% had major amputation, 8.7% had stroke, 6.5% required major limb intervention, and 2.2% had sepsis. Successful revascularization rate was 62.5% in the 24 patients who underwent open surgery vs 36.4% in the 11 patients who underwent endovascular repair. The average length of stay in the ICU was shorter in the open group (mean = 3.24 days) than in the endovascular group (mean = 8.60 days). Of the 11 patients who had no revascularization attempt, 36.4% died, 18.2% had a major amputation, 9.1% had a pulmonary embolism, and 9.1% had a stroke. COVID-19-associated ALI carries a high mortality. Patients with COVID-19 who develop ALI can be managed successfully with open surgery or endovascular intervention. In our cohort, open revascularization resulted in reduced ICU stay and reduced ventilation days with improved limb salvage than the endovascular group. Further data are needed to develop management algorithms for ALI in patients with COVID-19.TableRevascularization outcomesEndovascular (N = 11)Open (N = 24)None (N = 11)Overall (N = 46)Age, mean (SD)65.1 (6.17)60.8 (8.59)62.2 (13.6)62.2 (9.51)Diabetes mellitus4 (36.4)9 (37.5)5 (45.5)18 (39.1)Rutherford ALI scale I0 (0)0 (0)3 (27.3)3 (6.5) IIa4 (36.4)9 (37.5)2 (18.2)15 (32.6) IIb5 (45.5)14 (58.3)2 (18.2)21 (45.7) III2 (18.2)1 (4.2)4 (36.4)7 (15.2)No preoperative anticoagulation medication use6 (54.5)22 (91.7)22 (91.7)37 (80.4)No preoperative antiplatelet medication use3 (27.3)13 (54.2)7 (63.6)23 (50.0)Preoperative aspirin use18 (39.1)9 (37.5)4 (36.4)18 (39.1)Successful revascularization with symptom resolution4 (36.4)15 (62.5)0 (0)19 (41.3)Major amputation1 (9.1)1 (4.2)1 (9.1)4 (8.7)Ventilation in days, mean (SD)17.7 (9.61)10.6 (13.0)8.50 (7.78)12.3 (10.8)Average length of stay in ICU, days, mean (SD)8.60 (9.86)3.24 (4.96)3.29 (5.19)4.66 (6.85)Average length of stay in hospital, days, mean (SD)11.9 (10.5)12.8 (14.3)11.9 (10.5)13.2 (13.3)Death, in hospital3 (27.3)3 (6.5)4 (36.4)10 (21.7)Death, within 30 days1 (9.1)1 (4.2)0 (0)3 (6.5)ICU, Intensive care unit; SD, standard deviation.Data are presented as number (%) unless otherwise indicated. Open table in a new tab