Arterial Occlusion and Acute Limb Ischemia Induced Acute Deep Venous Thrombosis in COVID-19 Patients
Coronavirus disease 2019 (COVID-19) is a viral respiratory tract infection that is responsible for various thrombotic events in major blood vessels in the human body, especially deep vein thrombosis (DVT) and pulmonary embolism. [1]. These thromboembolic events are thought to arise from an immune and pro-inflammatory response that results in the production of procoagulation factors that are responsible for vascular injury. Despite the predominant venous etiology, rare reports now implicate COVID-19 in adverse arterial events such as arterial thrombosis that can lead to acute limb ischemia (ALI). [1]. ALI is an emergent vascular event that results in decreased limb blood flow and subsequent tissue hypoperfusion [2].
This article was previously presented as a poster at Michigan State University State University Emergency Medicine Resident Case Report Poster Day on February 16, 2022, and at the Henry Ford Health Systems Medical Education Research Forum on April 1, 2021.
A 69-year-old woman with a significant past medical history (PMH) for type 2 diabetes mellitus well controlled with metformin, presents to the emergency department (ED) with acute-onset left lower extremity pain (LLE) that started approximately eight hours earlier. for arrival. The patient described the pain as burning and throbbing and was rated 10/10. He denied all other symptoms, including, but not limited to, upper respiratory tract symptoms, nausea, vomiting, chest pain, dyspnea, cough, and abdominal pain.
He leads an active lifestyle, doesn’t sit much, hasn’t smoked his whole life, and has a normal body mass index. He denies any known history of atrial fibrillation, blood clots, or coagulopathy in himself or his family. He did not receive a COVID-19 vaccination. Vital signs showed the following: blood pressure 183/91, heart rate 90 beats per minute, respiratory rate 16 beats per minute, oxygen saturation 98% in room air, and no fever. The electrocardiogram shows a normal sinus rhythm without ischemic changes or abnormalities. Physical examination was significant for LLE swelling, discoloration with prominent erythema and mottling, and excruciating tenderness on palpation (Fig. 1). No palpable pulse of LLE was assessed at any location, including with the use of bedside Doppler ultrasound; a very concerning finding for ALI. There was no obvious deformity, signs of injury, or visible wound and the pulse in the right lower extremity was intact.
The patient’s initial laboratory examination was also unremarkable – complete blood count, baseline metabolic panel, and coagulation panel showed no disturbance of record. The patient was tested for COVID-19 as required for hospital admission and incidentally was found to be positive for COVID-19 polymerase chain reaction (PCR) RNA. He again denied any symptoms beyond his chief complaint or known exposure. Heparin infusion was started in the ED and she was urgently transferred to a tertiary care hospital for further evaluation by the vascular surgery team and escalation of care.
Upon arrival at the tertiary care hospital, extensive imaging was performed. LLE vein imaging showed acute total occlusion of DVT in the external iliac vein, common femoral vein, deep femoral vein, femoral vein, popliteal vein, posterior tibial vein, peroneal vein, and gastrocnemius vein. Computed tomography (CT) angiography showed focal base glass density in the lower lung plane, left common and external iliac artery occlusion, left popliteal artery and distal artery occlusion, and absence of three-vessel runoff to the associated left leg. LLE subcutaneous tenderness and muscle edema (Fig 2). CT imaging of the right lower extremity showed right peroneal artery occlusion in the middle leg (Fig 3) and right superficial femoral artery occlusion (Fig 4).
Additional laboratory testing performed revealed multiple disturbances, including elevations of the following inflammatory markers – d-dimer, ferritin, c-reactive protein, lactate dehydrogenase, erythrocyte sedimentation rate, and creatine phosphokinase. The patient eventually successfully underwent mechanical thrombectomy of the left iliac vein thrombus with removal of the acute blood clot combined with successful venoplasty and uncomplicated stent placement. He was declared medically cured and discharged home on the sixth day of hospital with aspirin, Plavix, enoxaparin to warfarin bridge, and primary care and follow-up outpatient vascular surgery.
COVID-19 predisposes infected individuals to hypercoagulable states resulting in venous and arterial thrombosis with venous lesions being the most common. COVID-19 infection causes a prolific inflammatory and systemic response culminating in microvascular changes, deposition of thrombotic factors in the microcirculation, and endothelial injury. During this process, the inherent anticoagulation properties of endothelial cells are inhibited, leading to cellular adhesion and vascular permeability that serve as the nidus for significant vascular occlusion. [1,3]. It is for these physiological reasons that clinicians must be acutely aware of the ability of COVID-19 to manifest in a variety of ways, including lesser-known sequelae that can result in disaster for the patient in question.
There are very few reports in the literature describing COVID-19 as the suspected etiology for concurrent arterial and venous thrombosis, with the majority being found in critically ill patients admitted to the intensive care unit (ICU). [3]. Of the reported cases, an extraordinary number is cited in patients with moderate to severe COVID-19 infection as there appears to be a correlation between the severity of COVID-19 disease and injury and multisystem organ dysfunction. A report in the literature describes ALI in patients treated for COVID-19 with antibiotics and corticosteroids. These patients had significant systemic disease at the time of their ALI diagnosis and were primarily hypotension, tachycardia, and hypoxia. [4]. Another report in the literature describes ALI in patients diagnosed with COVID-19 admitted to the ICU with intravenous enoxaparin, methylprednisolone, and tocilizumab for cytokine release syndrome in the setting of sharply elevated acute-phase reactants, inflammatory markers, and coagulation disturbances. factor. On the third day of hospitalization, the patient was found to have severe arterial insufficiency after blackening of the legs and hypothermia having no peripheral pulses were discovered. The vascular surgery team determined that the limb could not be saved and above the knee amputation was eventually performed [5].
Our patient’s presentation is unique in that he exhibits ALI in the setting of severe arterial occlusion and many acute DVTs are completely occlusive although otherwise asymptomatic from a viral respiratory syndrome standpoint. The prompt recognition of our patient’s severely compromised limb led to a prudent transfer to a higher level of care which resulted in diagnostic imaging and surgical intervention which ultimately resulted in a positive outcome despite initially having a poor prognosis with high mortality. [5].
ALI is a life-threatening vascular emergency that must be recognized and treated immediately as a way to prevent limb loss and death. Although COVID-19 is now known to cause hypercoagulable states leading to venous and arterial compromise, it is critical for clinicians to be aware that both entities can manifest simultaneously, especially in unsuspecting asymptomatic patients without risk factors. disease.
Our case underscores the need to broaden the differential diagnosis and consider ALI in patients infected with COVID-19 regardless of symptoms, especially as atypical manifestations continue to be explored. Similarly, COVID-19 infection should be considered in the differential diagnosis and patients should be tested for the virus when presenting clinical findings regarding coagulopathy. A high index of suspicion for this disorder will aid in early recognition, treatment of limb and life-saving, and reduction of overall morbidity and mortality.
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