key: cord-0819292-fx7t0zvq
authors: Andrea, Vacirca; Gianluca, Faggioli; Rodolfo, Pini; Paolo, Teutonico; Alessandro, Pilato; Mauro, Gargiulo
title: Unheralded Lower Limb Threatening Ischemia in a COVID-19 Patient
date: 2020-05-22
journal: Int J Infect Dis
DOI: 10.1016/j.ijid.2020.05.060
sha: 4eb0f78e44d8fce971534174b28dbc184718eeca
doc_id: 819292
cord_uid: fx7t0zvq

Acute thromboembolic events appear to be frequent in patients with SARS-CoV-2 infection. We report a case of an intubated patient, who developed a threatening lower limb ischemia. Intra-arterial fibrinolysis and intravenous heparin infusion did not lead to complete recanalization of the tibial arteries, which were successfully treated by surgical embolectomy.

The patient was diagnosed as SARS-CoV-2 infected; contamination occurred two weeks before with progressive worsening of the respiratory function, leading to orotracheal intubation and mechanical ventilation. Only chronic hypertension was found in the clinical history.

At admission in our unit, he showed moderate hypothermia of the right foot with initial skin marbling of the forefoot. Motility and sensibility could not be assessed, due to the deep sedation.

The right foot pulses, i.e. dorsalis pedis and posterior tibial, were absent, with all the other easily palpable bilaterally. The ultrasound examination confirmed the thrombotic obstruction of the tibial arteries of the right lower limb. Table I shows blood tests of the patient at admission. The patient had normal white blood   cells count, with neutrophilia and lymphocytopenia, normal Procalcitonin and elevated serum   Interleukin 6. INR, aPtt and platelets count were normal, with high value of D-dimer and Fibrinogen.

The clinical pattern indicated IIa acute limb ischemia, according with ESVS Guidelines 1 ; therefore, an urgent angiography through percutaneous right common femoral access was performed, in order to place a catheter for intra-arterial thrombolysis. The arteriography showed patent and normal femoro-popliteal axis, with distal occlusion of the anterior and posterior tibial arteries, as well as of the peroneal, which was distally recanalized (Figure 1 ). A 4F multi-hole catheter was advanced to the P3 segment of the popliteal artery and the tibio-peroneal trunk, with infusion of a 100.000 UI bolus of urokinase, followed by 50.000 UI per hour. Intravenous sodic Heparin was given at an anticoagulant dose. Serum Fibrinogen, INR, aPtt (target 1.7-2.3), CPK, Mioglobine and Creatinine were strictly monitored (every 6 hours), as shown in Table II . Two days after surgery, due to improved respiratory conditions, the patient was extubated, with pedal pulses still present and amelioration of the foot perfusion. At control CT-Scan, aortic thrombus disappeared (figure 2b).

This report deals with the sudden onset of thrombotic involvement of a healthy aorta of a COVID 19 patient, with subsequent thromboembolic occlusion of the tibial arteries, leading to a limb threatening ischemia. The problem of coagulopathy in COVID-19 is getting increasing interest in the discussion about this pandemic disease. As a matter of fact, the pandemic COVID-19 determined recently a very significant increase of admissions to intensive care unit (ICU) of patients needing ventilation support. Other than an acute respiratory distress syndrome (ARDS), many patients suffered a number of other problems, such as renal failure, cardiac arrhythmia, myocarditis and coagulative disorders. 2 Some authors suggested a possible role of disseminated intravascular coagulation; also, elevated D-dimer serum concentration has shown to be an independent risk factors for mortality in different experiences. 3, 4 Although no data are available about the role of a possible hypercoagulable status in severely diseased patients, it is suggested that heparin can play a role in reducing mortality in severe COVID-19 patients. However, the available data on the heparin role concern only patients with ARDS and septic status. 5, 6 J o u r n a l P r e -p r o o f

The case herein reported is characterized by an anomalous thrombus formation in a healthy abdominal aorta of a 58 year-old COVID-19 patient, which led to peripheral embolization, similarly to the cases reported by Zang et al. 7 Despite the similarity with those cases, a word of caution should be said before considering the SARS-CoV-2 a highly thrombotic virus. It is true that the thrombus arose suddenly in a healthy aorta in our case, and that anecdotal similar experiences are reported however two conflicting 

European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia

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