ACUTE LIMB ISCHEMIA IN A YOUNG ADULT WITH COVID-19 INFECTION

Abstract

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: COVID-19 infection is now well known to cause venous thrombotic complications. More recently, arterial thrombotic complications of COVID-19 have been reported. Incidence of Acute limb ischemia (ALI) ranges from 3 to 15%. CASE PRESENTATION: A 50-year-old male with a history of hypertension presented to the ED with left foot numbness, discoloration, and pain for 2 days. Two weeks before the presentation, he tested positive for SARS-CoV2 after an outpatient evaluation for acute cough. He did not have any other respiratory complaints and was quarantined at home. His cough persisted, but he denied any fever, shortness of breath, chest pain, or hemoptysis. On physical exam, he was afebrile, heart rate of 71 beats per minute, blood pressure 141/90 mm of Hg, respiratory rate of 19 breaths per minute, and oxygen saturation of 98% while breathing ambient air. His respiratory exam was unremarkable. There were no palpable femoral, popliteal, dorsalis pedis, and posterior tibial pulses on the left side. He had sensory loss in the left foot. Laboratory evaluation showed mild transaminitis. His CK was 767 U/L, and D-dimer was 4.92 mg/L. CTA abdominal aorta with iliofemoral runoff was performed, which showed partial occlusion of the distal abdominal aorta, near-complete occlusion of the left common iliac artery, and complete occlusion of the proximal popliteal artery at the level of the distal femur with no flow distal to this point.Anticoagulation with unfractionated heparin was initiated. The patient was emergently taken to the OR and underwent extensive embolectomy involving the aortoiliac, femoral, popliteal, and tibial artery of the left leg. Antiphospholipid antibodies were normal. He had no family or personal history of blood clots. His presentation was believed to be due to thrombotic complications of the COVID-19 infection. His postoperative course was unremarkable, and he was discharged home on postoperative day 5. DISCUSSION: ALI is a vascular emergency. The exact pathophysiology causing thrombosis is unknown, but endothelial dysfunction, cytokine production, acquired antiphospholipid syndrome, and hypoxia may contribute to thrombosis (1). The current prevalence of ALI is noted to be 4 to 21 per 100,000 COVID-19 hospitalizations. In one observational review and in most case series, the median age was over 60. Male sex, Hispanic ethnicity, history of myocardial infarction, CAD, and elevated D-dimer increase the risk of developing ALI (2). The patient usually presents with pain, pallor, numbness, and loss of pulses. CONCLUSIONS: We present a young patient with no significant risk factors and otherwise mild COVID-19 infection presenting with acute lower limb ischemia. A high index of suspicion and prompt recognition of ALI in patients with COVID-19 infection is critical. Surgical revascularization, either open or catheter-directed, and systemic anticoagulation is the mainstay of treatment. REFERENCE #1: Rahi MS, Jindal V, Reyes S-P, Gunasekaran K, Gupta R, Jaiyesimi I. Hematologic disorders associated with COVID-19: a review. Annals of Hematology. 2021. REFERENCE #2: Bilaloglu S, Aphinyanaphongs Y, Jones S, Iturrate E, Hochman J, Berger JS. Thrombosis in Hospitalized Patients With COVID-19 in a New York City Health System. Jama. 2020. DISCLOSURES: No relevant relationships by Kwesi Amoah, source=Web Response No relevant relationships by Kavitha Gopalratnam, source=Web Response No relevant relationships by Kulothungan Gunasekaran, source=Web Response No relevant relationships by Lakshmi Polisetty, source=Web Response No relevant relationships by Mandeep Singh Rahi, source=Web Response