ACUTE LIMB ISCHEMIA OF UPPER EXTREMITY IN PATIENTS WITH ACTIVE COVID-19 INFECTION
Keywords:
COVID-19, ALI, upper extremitiesAbstract
In the course of COVID-19 pandemic more and more evidences about the extrapulmonary tropismof SARS-CoV-2 are emerging. The virus affects the nervous system, excretory, digestive and cardiovascular systems as well. The cases of acute limb ischemia (ALI) are increasing with the emerging of COVID-19. ALI of the upper extremity in patients with COVID-19 reaches up to 16,7% of all cases of acute arterial thrombosis according to the literature.
Aim: Exploring the relative share of acute arterial thrombosis of the upper extremity and its complications in patients with COVID-19 infection.
Materials and methods: The study is retrospective, conducted in the period 21.07.2020 – 01.04.2021. The patients are separated in two groups: Group 1: patients with ALI, without clinical or laboratory evidence of COVID-19; Group 2 – patients with ALI and positive rapid antigen test or PCR for COVID-19. The patients are in class IIA or IIB under European Society of Vascular Surgery(ESVS)/Rutherford classification. Statistical analysis is performed with SPSS, variational and descriptive analysis is used. P value <0.05 is considered significant.
Results: Group 1: 828 extremities of which 52(6,3%) upper extremities, complications (32,7%), 1 (0,52%) case of amputation due to gangrene. Group 2: 47 patients, of which 32 (68%) with ALI. Ischemia of upper extremity - 8(25%), com - 3 (37,5%) arterial reconstruction rethrombosis, 1(12,5%) amputation due to gangrene. We discover statistically significant
difference in proportion of ALI in upper and lower extremities, in Group 2 ALI was diagnosed significantly more often (p<0,05). The count of postoperative complications in the two groups has no statistically significant difference (p>0,05). Patients in Group 2 were significantly more prone to gangrene and amputation of the upper extremity (p<0,05).
Discussion: This research demonstrates very high frequency of ALI of the upper extremity in patients with COVID-19 (25%), compared to the general population (6,2%), as well as higher possibility of complications (37,5%, vs 32,7%). Amputations of the upper extremity, due to gangrene are much more likely in patients with COVID-19 (12,5%), than in general population (0,52%, and 1,8% reported in the world literature).
Conclusion: SARS-CoV-2 infection has broad spectrum of symptoms. The big prevalence of arterial and venous occlusions in COVID-19 cases is associated with severe systemic inflammation, hipoxy and diffuse intravasal coagulopathy. It affects the microcirculation in the distal parts of the fingers of upper and lower extremities, which explains the encreased number of ALI.
References
Behzad, S., Aghaghazvini, L., Radmard, A.R., & Gholamrezanezhad, A. (2020). Extrapulmonary manifestations of COVID-19: radiologic and clinical overview, Clin. Imaging 66 35–41.
Björck, M. et al. (2020). European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia, European Journal of Vascular and Endovascular Surgery
Gupta, A., Madhavan, M.V., Sehgal, K., Nair, N., Mahajan, S., et al. (2020). Extrapulmonary manifestations of COVID-19. Nat Med 26: 1017-1032.
Eyers, P., & Earnshaw, J.J. (1998). Acute non-traumatic arm ischaemia. Br J Surg. Oct;85(10):1340-6. doi: 10.1046/j.1365-2168.1998.00884.x. PMID: 9782011.
Hernandez-Richter, T., Angele, M.K., Helmberger, T., Jauch, K.W., Lauterjung, L., & Schildberg, F.W. (2001). Acute ischemia of the upper extremity: long-term results following thrombembolectomy with the Fogarty catheter. Langenbecks Arch Surg. 386(4):261-266
Klok, F.A., Kruip, M.J.H.A., Meer, N.J.M., Van Der, A.M.S., Gommers, D.A.M.P.J., et al. (2020). Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res 191: 145-147
Kunutsor, S.K., & Laukkanen, J.A. (2020). Cardiovascular complications in COVID-19: a systematic review and meta-analysis, J. Infect. 81 (2) e139–e141.
Kunutsor, S.K., & Laukkanen, J.A. ( 2020). Hepatic manifestations and complications of COVID-19: a systematic review and meta-analysis, J. Infect. 81 (3) e72–e74.
Skeik, N., Soo-Hoo, S. S., Porten, B. R., Graber, J., Alden, P., Cragg, A., … Sullivan, T. (2015). Arterial Embolisms and Thrombosis in Upper Extremity Ischemia. Vascular and Endovascular Surgery, 49(5-6), 100–109. doi:10.1177/1538574415596740
Yana, E., Allan, M C., Jeffrey, S., Khalil, Q., Alfio, C., Pallavi, M.-S., Gary, G., Jonathan, S.D., et all (2021). Acute Arterial Thromboembolism in Patients with COVID-19 in the New York City Area Ann Vasc Surg 2021 Jan;70:290-294. doi: 10.1016/j.avsg.2020.08.085.
