Clinical Profile, Management Strategies, and Early Outcomes of Acute Limb Ischemia in Patients with COVID-19: A Prospective Observational Study

Abstract

Background: Coronavirus disease 2019 (COVID-19) is associated with endothelial dysfunction and a hypercoagulable state that may result in arterial thrombosis and acute limb ischemia (ALI). ALI may occur during active infection or in the post-COVID period and can result in substantial limb loss and mortality. This study evaluated the clinical profile, patterns of arterial involvement, management strategies, and early outcomes of COVID-19-associated ALI.

Methods: This prospective, non-randomized, single-centre observational study included 52 adult patients presenting with ALI during active COVID-19 infection or within 12 weeks following infection at Yashoda Super Speciality Hospitals, Hyderabad, between January 2021 and December 2022. Clinical presentation, comorbidities, COVID-19 status, laboratory parameters, Rutherford ALI classification, arterial distribution, treatment strategies, amputations, limb salvage, mortality, and follow-up outcomes up to four weeks were evaluated. A P value <0.05 was considered statistically significant.

Results: Of the 52 patients, 42 (80.9%) were male, and 65.4% were aged >50 years. Lower-limb involvement predominated (78%), and 42.3% developed ALI 2–3 weeks after COVID-19 infection. The most frequent comorbidities were type 2 diabetes mellitus (59.6%) and hypertension (48.1%), while 94.2% had elevated D-dimer levels. Clinically, coldness of the limb was present in 98.1%, pain in 84.6%, absent sensation in 21.1%, and gangrenous changes in 17.3%. Rutherford class IIb was the most frequent presentation (42.3%), followed by IIa (32.7%) and III (17.3%).

Popliteal and tibial arterial occlusions were the predominant anatomical pattern (55.8%), followed by brachial (15.4%) and femoral (11.5%) involvement. Open revascularization was performed in 40 patients (76.9%), most commonly popliteal trifurcation thromboembolectomy with vein patch angioplasty (34.6%). Trans femoral and trans brachial thromboembolectomy were each performed in 17.3%. Only one patient (1.9%) underwent endovascular thrombolysis with mechanical thrombectomy, while 11 patients (21.1%) received no revascularization because of irreversible ischemia or critical systemic illness. Fasciotomy was required in 17.3%.

Major amputation was required in 9 patients (17.3%), while 14 (26.9%) underwent minor amputations. The overall limb-salvage rate was 73%, and mortality was 19.2% (10/52). Diabetes (P=0.02), hypertension (P=0.003), coronary artery disease (P=0.006), and chronic kidney disease (P=0.018) were significantly associated with mortality.

Conclusion: COVID-19-associated ALI was characterized by predominant lower-limb involvement, frequent popliteal-tibial arterial thrombosis, elevated D-dimer levels, and a high prevalence of diabetes and hypertension. Most patients presented with threatened limbs requiring active revascularization, with open surgery being the predominant treatment strategy. Despite a 73% limb-salvage rate, major amputation and mortality occurred in 17.3% and 19.2%, respectively. Early recognition, appropriate anticoagulation, prompt assessment of limb viability, and timely revascularization remain central to optimizing early outcomes.