key: cord-1016952-f0l1ptq2
authors: Vo, Trung D.; Daoud, Amanda; Jeney, Ashtin; Andacheh, Iden; Behseresht, Jason; Hsu, Jeffrey; Tayyarah, Majid; Slezak, Jeff
title: COVID-19 Related Peripheral Arterial Thrombosis Treated in a Large Health Managed Organization
date: 2022-04-22
journal: Ann Vasc Surg
DOI: 10.1016/j.avsg.2022.04.024
sha: a4b2c70acf9128a32ba1de26c33644b073115bb4
doc_id: 1016952
cord_uid: f0l1ptq2

OBJECTIVES: COVID-19 was initially identified as an acute respiratory disease but it was quickly recognized that multiple organ systems could be affected. Complications of venous thrombosis and pulmonary embolism have been well reported. However, there is a paucity of data on COVID-19 related arterial thrombosis. The aim of this study was to examine the incidence, characteristics, treatment and outcome in patients with acute COVID-19 related arterial thrombosis in a large health maintenance organization (HMO). METHODS: A retrospective multi-center case review was performed from March 2020 to March 2021. Cases were identified through a questionnaire sent to vascular surgeons at each of the HMO associated hospitals. Patient characteristics, imaging, treatment and outcome were reviewed. Successful revascularization was defined as restoration of blood flow with viability of the end organ and absence of death within 30 days. Limb salvage was defined as prevention of major amputation (transtibial or transfemoral) and absence of death in 30 days. RESULTS: There were 37,845 patients admitted to our associated hospitals with COVID-19 complications during this time. Among this group, 26 patients (0.07%) had COVID-19 related arterial thrombosis. The mean age was 61.7 years (range 33-82 years) with 20 men (77%) and 6 women (23%). Ethnic minorities comprised 25/26 of cases (96%). Peripheral arterial disease (PAD) was present in 4/26 (15%), active smoking in 1/26 (3.8%), and diabetes in 19/26 (73%). Most patients developed acute arterial ischemia in the outpatient setting, 20/26 (77%). Of the outpatients, 6/20 (30%) had asymptomatic COVID-19 and 14/20 (70%) had only mild upper respiratory symptoms. Distribution of ischemia was as follows: 23 patients had at least one lower extremity ischemia, one patient had cerebral and lower extremity, one had mesenteric and lower extremity, and one had upper extremity ischemia. Revascularization was attempted in 21 patients, of which 12/21 (57%) were successful. Limb salvage was successful in 13/26 (50%). Overall mortality was 31% (8/26). CONCLUSIONS: Our experience in a large HMO revealed that the incidence of COVID-19 related arterial thrombosis was low. The actual incidence is likely to be higher since our method of case collection was incomplete. The majority of arterial thrombosis occurred in the outpatient setting in patients with either asymptomatic or mild/moderate COVID-19 respiratory disease. Acute ischemia was the inciting factor for hospitalization in these cases. Acute lower extremity ischemia was the most common presentation and limb salvage rate was lower than that expected when compared to ischemia related to PAD. Arterial thrombosis associated with COVID-19 portends a significantly higher mortality. Education of primary care providers is paramount to prevent delayed diagnosis as most patients initially developed ischemia in the outpatient setting and did not have a high cardiovascular risk profile.

patients, of which 12/21 (57%) were successful. Limb salvage was successful in 13/26 (50%). 24 Overall mortality was 31% (8/26). 25 Conclusions: Our experience in a large HMO revealed that the incidence of COVID-19 related 26 arterial thrombosis was low. The actual incidence is likely to be higher since our method of case 27 collection was incomplete. The majority of arterial thrombosis occurred in the outpatient setting 28 in patients with either asymptomatic or mild/moderate COVID-19 respiratory disease. Acute 29 ischemia was the inciting factor for hospitalization in these cases. Acute lower extremity 30 ischemia was the most common presentation and limb salvage rate was lower than that expected 31 when compared to ischemia related to PAD. Arterial thrombosis associated with COVID-19 32 portends a significantly higher mortality. Education of primary care providers is paramount to Introduction 36 COVID-19 was initially recognized in Wuhan, China in December 2019 and by January 2020 37 the first cases in the United States were reported. By March 2020, COVID-19 was declared a 38 pandemic primarily recognized to cause acute respiratory distress. However, it became apparent 39 that COVID-19 impacted multiple organ systems. In particular, complications of unprovoked 40 venous thrombosis were noted. This has been postulated to be due to a severe inflammatory 41 response that incites a generalized hypercoagulable state. 1 The earliest studies on COVID-19 42 coagulopathy suggested that an increase in the vasoconstrictive Angiotensin II as well as a 43 decrease in the vasodilator angiotensin, and the release of cytokines secondary to sepsis 44 combined to trigger a hypercoagulable state. 2 Others have postulated that increased autoimmune 45 antibodies may incite an inflammatory state predisposing to thrombosis. 3 Venous thrombosis has been extensively reported while COVID-19 related arterial thrombosis has been less well 47 described. We report our case series of 26 patients presenting with COVID-19 related arterial 48 thrombosis.

A retrospective multi-center case review was performed for patients with acute COVID-19 Table 2 . Most patients presented from the outpatient setting at 77% (20/26). (Table 3) . One patient underwent primary amputation while 28.6% (6/21) of 86 patients required a secondary amputation after failed surgical or endovascular thrombectomy. 87 Ultimately, the successful revascularization and limb salvage rate was relatively low at 50% 88 (13/26) and mortality was high at 30.8% (8/26).

Mortality was examined in relation to demographics (Table 4) (Table 5 ). The mean number of morbidities did not differ significantly among those 94 who survived versus died (Table 6) .

Amputation outcomes were analyzed against each demographic factor and comorbidity (Table   96 7). Age was associated with an inverse relationship to likelihood of amputation. Both obesity and 97 hypertension had a significantly increased risk of amputation. Diabetics had a higher amputation 98 rate but this did not reach statistical significance.

The actual incidence of COVID-19 related arterial thrombosis is difficult to calculate but 101 appeared to be low in our HMO during the COVID-19 pandemic of 2020-2021. The reported 102 value only captures severe cases requiring Vascular Surgery intervention and likely 103 underestimates the true incidence given it was based on a voluntary query of providers. In 104 addition, it could be argued that the relationship with acute ischemia and COVID-19 could be 105 incidental in some of our patients. 106 We found that the majority of patients affected with COVID-19 arterial thrombosis were ethnic

Our experience in a large HMO revealed that the incidence of severe COVID-19 related arterial 136 thromboembolic events requiring in patient hospitalization and Vascular Specialist consultation 137 was low. The majority of arterial thrombosis occurred in the outpatient setting in patients with 138 either asymptomatic or mild/moderate COVID-19 respiratory disease. Acute ischemia was the 139 inciting factor for hospitalization in these cases. Acute lower extremity ischemia was the most 140 common presentation and limb salvage rate was lower than that expected for ischemia related to 141 PAD. Arterial thrombosis associated with COVID-19 portends a significantly higher mortality. J o u r n a l P r e -p r o o f J o u r n a l P r e -p r o o f J o u r n a l P r e -p r o o f J o u r n a l P r e -p r o o f J o u r n a l P r e -p r o o f 

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