Acute arterial thrombosis in patients admitted with COVID-19 infection: Clinical experience
Authors: Mohialdeen Sameer , Hummadi Fayadh Noor Abbas , Khaleel Al-Anbari Abbas Jaafar , Maddah H. Al-Alosi Bassam 
Published: June 2022

Background: Acute limb arterial thrombosis (LAT) is defined as a sudden reduction in arterial supply to the extremity to a degree that affects its viability. Patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease 2019 [COVID-19]) have unbalanced coagulation profiles and are prone to thromboembolic events. Prompt diagnosis of LAT and appropriate urgent intervention, whenever possible, can help decrease morbidity and mortality among these patients and increase the chance of limb rescue. Therefore, this was the stimulus for this study, where based on our clinical experience, we aimed to identify the prevalence and analyze the outcomes of acute LAT in patients admitted with COVID-19 in Baghdad, Iraq. Methods: This study included 135 patients admitted with COVID-19, aged 35–70 years. During admission, these patients were referred to the consultation vascular surgeons because of ischemic changes in their limbs. History, demographics, clinical history, and laboratory tests were collected from all the patients. Vascular Doppler ultrasound and CT angiography were performed in some patients (especially those with re-thrombosis) to finalize the diagnosis and to plan for vascular intervention. Appropriate therapeutic anticoagulants were immediately initiated and once the diagnosis of LAT was established, surgical intervention (under local anesthesia), including thrombo-embolectomy and revascularization, was performed. After postoperative management and anticoagulation were completed, post discharge followup was the final step. Results: The mean age of the enrolled patients was 55.3 ± 7.8 (range 35.1–70.9) years, 86 (63.7%) were males. The mean number of days after the initial COVID-19 manifestation was 22 (16–28). The mean serum levels of D-dimer, CRP, and ferritin were high (795.8 ng/mL, 49.1 mg/mL, and 994.7 ng/mL, respectively). The prevalence of associated risk factors including diabetes, hypertension, and ischemic heart diseases was relatively high. Two-thirds of the patients with LAT had involvement of lower limbs and mostly (69.6%) on the left side. The men represented more than half of the patients affected by LAT in their lower limbs. Re-thrombosis was encountered in 29.6% of the patients, mostly women. Of the total 135 patients with LAT, 14 (10.4%) underwent surgical amputation on presentation to surgical wards or afterwards, however; and unfortunately, 13 (9.6%) of the total patients with LAT died. Most of the recorded mortality among the patients with LAT occurred during hospitalization for COVID-19, nine (75%), regardless of their etiologies. Conclusions: COVID-19 is associated with a high risk of thromboembolic events including LAT. Those with blood group A tend to develop more “re-thrombotic events” than other groups. Even with the successful prescription of prophylactic anticoagulants, young and otherwise healthy cases may be prone to LAT. In patients with COVID-19 and owing to their hypercoagulable state, the surgical intervention of LAT might be harder and more challenging than anticipated. Cardiovascular surgeons and physicians should consider the benefits of extended postoperative anticoagulant administration.