COVID-19 and Acute Limb Ischemia: A Systematic Review

The extraordinary prothrombotic manifestations of Coronavirus Disease-2019 (COVID-19), caused by severe acute respiratory syndrome CoV (SARS-CoV-2) virus, presenting as venous and arterial thrombosis have been reported in the literature. The incidence of arterial thrombosis is reported to be 4% in critically ill COVID-19 patients.. Arterial thrombosis in the setting of COVID-19 has been reported to occur in a multitude of organs leading to ischemic strokes, ST-segment elevation myocardial infarction, aortic thrombus and acute limb ischemia. Diffuse endothelial activation, along with aberrant immuno-thrombotic mechanisms have been implicated in the widespread thrombosis occurring in COVID-19 patients. We performed a literature review of 55 reported cases to delineate the clinical characteristics, management patterns and outcomes of patients with COVID-19 who developed complications of acute limb thrombosis and ischemia. Our systematic review revealed that acute limb ischemia had a male predominance, with either hypertension or diabetes mellitus as the most common underlying cardiovascular risk factors. Aortic thrombus was reported in 23.6% of the cases. The majority of the cases involved thrombosis in more than one limb, indicative of a diffuse thrombotic state. The most common artery affected was the left popliteal artery. Upper limb thrombosis occurred in 40% of the cases. Most of the cases (74.5%) were managed with urgent revascularization interventions and anticoagulation. Negative outcomes, including amputations (14.9%) and death (26.5%) occurred at a higher rate in this population, despite the use of standard management.