Resident Physician Burke Rehabilitation Hospital White Plains, New York, United States
Case Diagnosis: COVID-19 Acute Limb Ischemia
Case Description: 65 year-old male with past medical history of type 2 diabetes presented to acute care with one day of right lower extremity paresthesias and calf pain. One week prior to admission, the patient was tested positive for COVID-19. CTA on admission demonstrated multiple areas of acute thrombotic disease including the right common iliac artery, deep femoral artery and popliteal artery. D-dimer elevation was noted. Lupus anticoagulant was positive. Life threatening limb-ischemia was subsequently determined despite intravenous heparin. After decreasing oxygen requirements, the patient underwent right lower extremity iliac artery stent placement and right guillotine below the knee amputation.
Discussions: Although COVID-19 is known for its predominantly respiratory sequelae, coagulopathy has continued to emerge to be a debilitating complication. The majority of reports on the high incidence of thrombotic complications are in relation to deep venous thrombosis and pulmonary embolisms. Arterial thrombosis is less cited with minimal clarity in the mechanism and guidelines to management. We report a rare case of peripheral arterial thrombosis associated with COVID-19 resulting right transtibial amputation. It is likely our patient failed both pharmacological and surgical intervention in the setting of an unpredictable hypercoagulable state from this virus.
Conclusions: COVID-19 has demonstrated clear association with a hypercoagulable state resulting in both venous and arterial thrombosis. Arterial thrombosis appears to be a rare occurrence in the literature thus far. Our case adds to the literature of acute limb ischemia in the setting of COVID-19. Very little data on the incidence and consequences of peripheral arterial thrombotic events exists. Awareness of COVID-19 risk of arterial thrombosis is warranted. The mechanism and management of this process remains in question. A retrospective study on these events would be beneficial for the management of this sequelae to improve surgical treatment efficacy, limb salvage and overall survival.