key: cord-0877491-osek7g0q
authors: Soares, Rafael de Athayde; Futigami, Aline Yoshimi; Barbosa, Anndya Gonçalves; Sacilotto, Roberto
title: Acute arterial occlusions in covid-19 times: a comparison study among patients with acute limb ischemia with or without Covid-19 infection
date: 2022-04-20
journal: Ann Vasc Surg
DOI: 10.1016/j.avsg.2022.04.006
sha: 73ebcea9a37b214bf55cef6156275ff6f3bc8beb
doc_id: 877491
cord_uid: osek7g0q

OBJECTIVE: To determine the impact of COVID-19 infection in patients with acute limb ischemia (ALI), mainly the limb salvage estimates rate and the overall survival rate. METHODS: This was a prospective, consecutive cohort study of ALI patients with or without COVID-19 infection. Two groups of patients were identified: patients with ALI and COVID-19 infection and patients with ALI, without COVID-19 infection. The comparisons among the two groups were performed with proper statistical analysis methods. RESULTS: Two groups of patients were identified: ALI and COVID-19 infection with 23 patients and ALI without COVID-19 infection, with 49 patients. The overall mortality rate (OMR) was 20.8% (15 patients) in total cohort within the first 30 days. Covid-19 group had a higher OMR than non-Covid-19 group (30.4% versus 16.7%, p = 0.04). The limb salvage rate at 30 days was 79.1% in total cohort, however non-Covid-19 infection group had a higher limb salvage rates than Covid-19 infection group (89.7% versus 60.8%, p = 0.01). A univariate and multivariate logistic regression was performed to test the factors related to major amputation rate. Among the factors evaluated, the following were related to limb loss: d-Dimer > 1000mg/ml (HR = 3,76, p = 0.027, CI = 1,85 – 5,89) and COVID-19 infection ((HR = 1,38, p = 0.035, CI = 1.03-4.75). Moreover, a univariate and multivariate logistic regression analysis was performed in order to analyze the factors related to overall mortality. Among the factors evaluated, the following were related to overall mortality rate: D-dimer > 1000mg/dl (HR = 2.28, p = 0.038, CI: 1.94-6.52), Covid-19 infection (HR = 1.8, p = 0.018, CI = 1.01-4.01) and PMT > 150 cycles (HR = 2.01, p = 0.002, CI = 1.005-6.781). CONCLUSION: COVID-19 has a worse prognosis among patients with ALI, with higher rates of limb loss and overall mortality relative to non-COVID patients. The main factors related to overall mortality were D-dimer > 1000mg/dl, Covid-19 infection, and PMT > 150 cycles. The factors related to limb loss were d-Dimer > 1000mg/ml and COVID-19 infection.

The comparisons among the two groups were performed with proper statistical 23 analysis methods. 24

Results: Two groups of patients were identified: ALI and COVID-19 infection with 25 23 patients and ALI without COVID-19 infection, with 49 patients. The overall 26 mortality rate (OMR) was 20.8% (15 patients) in total cohort within the first 30 days. 27

Covid-19 group had a higher OMR than non-Covid-19 group (30.4% versus 16.7%, p 28 = 0.04). The limb salvage rate at 30 days was 79.1% in total cohort, however non-29

Covid-19 infection group had a higher limb salvage rates than Covid-19 infection 30 group (89.7% versus 60.8%, p = 0.01). A univariate and multivariate logistic 31 regression was performed to test the factors related to major amputation rate. Among 32 the factors evaluated, the following were related to limb loss: d-Dimer > 1000mg/ml 33 (HR = 3,76, p = 0.027, CI = 1,85 -5,89) and COVID-19 infection ((HR = 1,38, p = 34

Acute limb ischemia (ALI) continues to be a threatening and challenging emergency 67 in vascular surgery, despite the advances in technology and material, and may lead to 68 major amputations and death, if not treated properly. 1 Furthermore, ALI represents 69 one of the most common and dreadful emergencies in vascular surgery, with an 70 incidence ranging from 10 to 22 per 100,000 patients per year. 2 71

The novel coronavirus pneumonia (COVID-19) pandemic has afflicted the worldwide 72 large amount of thrombus in the operating room. Procedures such as debridement and 117 minor amputations were performed, as necessary, during hospitalization. The COVID-118 19 infection was treated and controlled both by the vascular surgeon team, and by the 119 infectious disease team, and, if necessary, by the intensivist. All Similarly, there are reports in overall literature describing overall mortality rate of 25% 232 and limb loss of 25% among patients infected with Covid-19 and ALI. 10 These data are 233 comparable with those found in this present study, whereas the overall mortality rate 234 among patients with COVID-19 and ALI was 30.4% and the rate of limb loss was 235 39.2%, which was higher than the patients with ALI and non-COVID-19 infection. 236

Furthermore, the patients in this present cohort with Covid-19 infection and ALI were 237 most of them classified as Rutherford IIb, denotating higher levels of ischemia when 238 compared to patients with ALI and non-Covid-19 infection. Overall, the mortality rate the cause of death has been attributed to respiratory failure, sepsis, cardiac failure, 241 kidney injury, or the consequences of coagulation abnormalities. Among patients who 242 develop ALI, mortality rates are as high as 50 percent. 6 In a review of 571 COVID-19 243 patients, the risk of death was nearly three-fold higher in patients who had arterial 244 thrombotic events (hazard ratio 2.96, 95% CI 1.4-4.7). 5,6 This review showed that a 245 concentration of D-dimer above 1250 ng/mL increased the risk of arterial thrombotic 246 events in COVID-19+ patients by more than 7 (subdistribution hazard ratio, 7.68; 95% 247 CI, 2.9 to 20.6; P<.001). Similarly, in this present study, univariate and multivariate 248 logistic regression analysis showed that d-Dimer higher than 1000mg/dl was related to 249 overall mortality (HR = 2.28, p = 0.038, CI: 1.94-6.52) and limb loss (HR = 3,76, p = 250 0.027, CI = 1,85 -5,89). Furthermore, the COVID-19 group had higher D-dimer and 251 CPK rates than non-covid-19 group (1520mg/dl versus 689 mg/dl, p = 0.04 and 252 1239mg/dl versus 580 mg/dl, p = 0.03, respectively). These data probably should have 253 collaborated to the higher rates of mortality rate and limb loss among patients with 254

Recently, an important trial with 1098 patients showed that in critically ill patients with 256

Covid-19, an initial strategy of therapeutic-dose anticoagulation with heparin did not 257 result in a greater probability of survival to hospital discharge or a greater number of 258 days free of cardiovascular or respiratory organ support than did usual-care 259 pharmacologic thromboprophylaxis. 12 The percentage of patients who survived to 260 hospital discharge was similar in the two groups (62.7% and 64.5%, respectively; 261 adjusted odds ratio, 0.84; 95% credible interval, 0.64 to 1.11). Major bleeding occurred 262 in 3.8% of the patients submitted to therapeutic-dose anticoagulation and in 2.3% of 263 those who received usual-care pharmacologic thromboprophylaxis. Specifically, in this 264 present paper all patients were submitted to therapeutic-dose anticoagulation, due to major thrombotic events such as acute limb ischemia and the necessity of therapeutic 266

anticoagulation. This type of comparison was not performed in this present paper, 267 however it is important to notice that these patients in this present cohort presented with 268 a major complication, such as ALI, which has a considerable morbidity and mortality 269 in patients with and without Covid-19 infection. 

Analysis of the Safety and Efficacy of the Endovascular Treatment for Acute Limb 325

Ischemia with Percutaneous Pharmacomechanical Thrombectomy Compared with 326

Population-Based Study of Incidence, Risk Factors, Outcome, and 329 Prognosis of Ischemic Peripheral Arterial Events: Implications for

Abnormal coagulation parameters are associated 332 with poor prognosis in patients with novel coronavirus pneumonia

Acute limb ischemia in patients with COVID-19 342 pneumonia

The Need of Research Initiatives Amidst and After the 344

Covid-19 Pandemic: A Message from the Editors of the EJVES

Arterial Thromboembolism in Patients with COVID-19 in the

Lower extremity arterial 350 thrombosis associated with COVID-19 is characterized by greater thrombus burden and 351 increased rate of amputation and death

Acute Arterial Occlusions in Patients 353 with COVID-19: results and outcomes

The looming storm: Blood and cytokines in COVID-19

aminophylline does not prevent AngioJet rheolytic thrombectomy-induced 366 bradyarrhythmias

Type III heart block with peripheral use 368 of the AngioJet thrombectomy system

Comparison of the AngioJet rheolytic 370 catheter to surgical thrombectomy for the treatment of thrombosed hemodialysis grafts

Comparative effectiveness of endovascular versus surgical revascularization for acute 374 lower extremity ischemia

Analysis of the results of endovascular and open 377 surgical treatment of acute limb ischemia