SLR - September 2023 - Coker
Title: COVID-associated acute limb ischemia during the Delta surge and the effect of vaccinesReference: Xie B, Semaan DB, Binko MA, Agrawal N, Kulkarni RN, Andraska EA, Sachdev U, Chaer RA, Eslami MH, Makaroun MS, Sridharan N. COVID-associated acute limb ischemia during the Delta surge and the effect of vaccines. J Vasc Surg. 2023 Apr;77(4):1165-1173.e1. doi: 10.1016/j.jvs.2022.12.002. Epub 2022 Dec 13. PMID: 36526086; PMCID: PMC9744677.
Level of Evidence: III
Scientific Literature Review
Reviewed By: David Coker, DPM
Residency Program: Boston Medical Center, Boston, MA
Podiatric Relevance: Acute Limb Ischemia (ALI) is considered a severe and rapid decrease in perfusion of blood to extremities and poses a threat to limbs and life prognosis if not quickly and appropriately treated. Covid-19, specifically the DELTA strain, was noted to cause hypercoagulability in severe respiratory syndromes and has been seen to cause arterial thrombosis. This study looked at patients that were admitted for or developed ALI and had a recent COVID-19 infection. This allows for further ischemic limb understanding and research for the podiatric specialty and COVIDs effects on mortality and limb loss.
Methods: A retrospective review from 2023 journal of vascular surgery evaluating the incidence of COVID-19-associated ALI across at a single health care, multi-hospital network between January of 2020 and March of 2022. Approved by The University of Pittsburgh Institutional Review Board. The electronic medical record (EMR) was queried for patients aged >18 years with ALI and a recent (<14 days) COVID-19 positive test or for those who developed limb ischemia during hospitalization for COVID-19 and was compared to patients with ALI over the 2 years prior to the COVID-19 Pandemic. Primary outcomes were the cause of in-hospital mortality and 30-day amputation-free survival. Secondary outcomes included hospital length of stay and major adverse limb events.
Results: 40 COVID-19-associated ischemic limbs in 36 patients were identified throughout the study period compared to 74 ischemic limbs in 68 patients in the pre-COVID-19 cohort. 13,522 cases of COVID-19 hospitalization were identified in the health care network between 2020 and 2021. The rate of COVID-19-associated ALI nearly doubled during the Delta surge. The primary outcome, Postoperative in-hospital mortality was 48%, and overall mortality was 50% in the COVID-19-associated ALI cohort. Almost all deaths in the COVID-19-associated ALI cohort were COVID-19-related. The 30-day amputation-free survival in the COVID-19-associated ALI group was 45%, which was significantly lower than the pre-COVID-19 cohort (89%). There was also a significantly longer length of stay (19.3 ± 14.1 days vs 10.4 ± 9.3 days; P < .001) within the COVID-19-associated ALI group as compared with the control. In Subgroup Analysis the instances of COVID-19-associated ALI occurred almost exclusively in nonvaccinated patients, with only two vaccinated individuals presenting during the Delta surge with concurrent infection and limb ischemia. Of note the average age of the COVID-19-associated ALI cohort was significantly older than the pre-COVID-19 group (69.1 ± 11.4 years vs 63.3 ± 14.4 years; P = .03).
Conclusions: This study showed that limb ischemia in the setting of acute COVID-19 infection is associated with significant mortality and an increased risk of limb loss despite revascularization. The study can aid foot and ankle surgeons, and the multidisciplinary teams that treat these patients, to better understand ALI and covid's effects on mortality and limb loss.