Lower-extremity Arterial Thrombosis Associated with COVID-19 Is Characterized by Greater Thrombus Burden and Increased Rate of Amputation and Death

Abstract

C oronavirus disease 2019 (COVID-19) caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is characterized by the respiratory symptoms implicit in the name severe acute respiratory syndrome. Still, with the increasing number of cases, it has also been linked to nonpulmonary targets, including cardiac, gastrointestinal, skin, renal, and neurologic manifestations (1-5). Venous thromboembolism has also been shown to be an important cause of morbidity and mortality in patients with COVID-19, both in the general inpatient and in the intensive care unit (ICU) setting, and even in patients receiving therapeutic anticoagulation (6-8). For example, in one autopsy series, unsuspected deep vein thrombosis was found in the majority of patients with COVID-19, and pulmonary embolism was the cause of death in one-fourth of these patients (9). Arterial thrombosis has also been reported within coronary arteries (6,10) and within the brain (6,11) in patients with COVID-19. There have also been case reports regarding mesenteric (12-14) and aortoiliac (6,12) thrombosis. In our practice, in a COVID-19 hotspot, where at its peak (April 12, 2020) our hospital system had 1194 inpatients with diagnosed COVID-19, we have observed an increased number of patients presenting with lowerextremity ischemia and extensive arterial thromboses during the current pandemic. These patients typically presented to the emergency department with new symptoms of leg pain, coldness, discoloration, and ulceration, and they underwent lower-extremity CT angiography. Diagnostic work-ups in many of these patients showed them to be positive for the SARS-CoV-2 virus. With growing evidence of coagulopathy or vasculopathy (15) in patients with COVID-19, we investigated whether these cases were also due to COVID-19-related thrombosis. The goal of

COVID-19 associated multi organ embolism and critical limb ischaemia followed by limb salvage: A case report

“…In the absence of any evidence of cardiac source we speculate that the thrombus formation is occurring in the setting of a hypercoagulable state and is most likely in the form of large-vessel mural thrombus formation. This is similar to what was seen by Goldman et al in the cases they described 6 . A paradoxical embolus (venous thrombosis with a patent foramen ovale) is another possibility.…”

“…Study by Goldman et al demonstrated an association between COVID-19 and lower extremity arterial thrombosis with greater thrombus burden characterized by predilection for proximal arteries 6 . They suggested that COVID-19 is associated with lower extremity arterial thrombosis characterized by greater clot burden and a direr prognosis.…”

Acute Limb Ischemia in a Peruvian Cohort Infected by COVID-19

“…respectively. 6,36 This amputation rate is higher than in patients with acute arterial thrombosis without COVID-19 infection reported in the USA and England. 37,38 Our high amputation rate could be explained because of elevated number of patients with severe COVID-19 infection (53.3%) and…”

COVID-19 Infection: Viral Macro- and Micro-Vascular Coagulopathy and Thromboembolism/Prophylactic and Therapeutic Management

“…A recent study comparing 16 patients with COVID-19 (age 70 ± 14 years, 7 women) undergoing lower extremity CT angiogram (CTA) with 32 propensity-score matched control patients (age 71 ± 15 years, 16 women), showed that all COVID-19 patients had at least 1 arterial thrombus while only 69% of controls had arterial thrombi (p = 0.02); proximal thrombi were present in 94% of COVID-19 patients compared with 47% of controls (p < 0.001). 35 Death or limb amputation was more common in COVID-19 patients (odds ratio-OR 25, p < 0.001).…”