Complex liver injuries can be managed successfully with conservative treatment in majority, with low mortality and acceptable morbidity. Surgery is reserved for selected indications.

Objective: To determine the outcomes following various surgical and medical treatments of Coronavirus disease 2019 (COVID-19) induced acute limb ischaemia. Methods: A retrospective study of patients presenting with COVID induced arterial ischaemia in three hospitals from Southern India during the months of May 2020 to August 2021 was undertaken. These patients were managed by either thrombectomy, primary bypass, thrombolysis, anticoagulation or primary amputation based on the stage of ischaemia and the severity of COVID. Results: A total of 67 limbs in 59 patients were analysed. The average time to intervention was 15 days. Upper limb involvement was seen in 16 and lower limb in 51 limbs. Of the 67 limbs, 39 (58.2%) were treated by open surgical revascularisation, 5 (7.4%) by catheter directed lysis, 17 (25.3%) were managed conservatively and 6 (8.9%) underwent primary amputation. Successful revascularisation could be carried out in 88.6% of patients. A limb salvage rate of 80.6% was achieved in these patients with a re-intervention rate of 13.6%. Major amputation rate was 14.92% and mortality was 13.56%. Conclusion: Limb ischaemia after COVID can be safely managed by open thrombectomy or bypass. Similar rates of limb salvage as in non-COVID acute limb ischaemia can be obtained.

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An 18-year-old asymptomatic girl was found to have prominent pulsations in the neck during evaluation for cosmetic ear surgery. At 6 months of age, she had undergone division and suturing of patent ductus arteriosus with a large left-to-right shunt, pulmonary arterial hypertension, and congestive heart failure. On examination, she had thrusting pulsations on both sides of the neck and the supraclavicular regions. The right radial pulse was feeble, and bruit was heard over both carotid arteries and the supraclavicular fossae. The left radial pulse and both lower limb pulses were near normal. Blood pressure was equal in left upper and both lower limbs at 160 mm Hg; right arm pressure was 120 mm Hg. Computed tomographic angiogram revealed interrupted aortic arch distal to the origin of the left common carotid artery. Multiple dilated tortuous collaterals were seen arising from the vertebral arteries and external carotid artery, retrogradely filling the descending thoracic aorta. Right subclavian artery showed short segment occlusion after its origin (A). Surgery through a posterolateral thoracotomy was planned. Central aortic pressures were recorded intraoperatively using a 20-mm cannula in the left superficial temporal artery. A 10-mm albumin-coated polyester graft (Albograft, Edwards Life Sciences SA, Nyon, Switzerland) was sutured to the left common carotid artery proximally and to the descending thoracic aorta distally to reestablish aortic continuity. The gradient decreased from 40 mm Hg in the preoperative period to <10 mm Hg in the postoperative period. Computed tomographic angiogram performed during follow-up revealed an intact repair and a normally functioning "neoarch" (B).