Acute limb Ischemia Rutherford Classification III and COVID-19: A case

report

ABSTRACT

COVID-19 is caused by SARS-CoV-2 infections, which are responsible for the

recent pandemic. COVID-19 infection is associated with an increased incidence of

thromboembolic events, including acute limb ischemia (ALI). COVID-19 causes

elevated cytokine levels, systemic inflammation, hypercoagulation state, and

hyperinflammation responses are responsible for arterial system damages, causing

endothelial dysfunction. Without any treatment, ALI might cause loss of the

limbs. Amputation procedure is the treatment option for managing ALI patients.

We reported a case of 61 years old male with ALI and COVID-19 infection with

main complaints of pain in his left leg accompanied by tingles and bluish in his

left leg. The patient had been admitted due to COVID-19 before. Debridement

and left limb amputation was done.

INTRODUCTION cases of arterial thrombosis in

COVID-19 is a pathological patients with COVID-19,

condition caused by severe acute conditioning acute limb ischemia

respiratory syndrome coronavirus 2 (ALI) and constituting a surgical

(SARS-CoV-2) infection. Since the emergency.1

first cases reported in Wuhan, the Despite most of the cases being

symptoms of the infection have not asymptomatic, further primary

been specific and are frequently preventions are extremely important.

associated with pulmonary Primary health care facilitators play

complications.1 an important role in early diagnosis

Different extrapulmonary and managing patients with ALI

manifestations have been described symptoms or risk factors, specifically

related to acute thromboembolic with a history of COVID-19.

phenomena in the context of a Managements are variable depending

systemic inflammatory state, on other comorbidities. A good

endothelial injury, and platelet management strategy is going to

dysfunction at cardiopulmonary, increase patients’ quality of life. In

cerebrovascular, and peripheral the following, we reported a case of

venous and arterial level, affecting as 61 years old male with Acute limb

high as 49% of patients and Ischemia Rutherford Classification

overshadowing the prognosis of the III associated with COVID-19.

disease. Recent publications have Case Report

described a sud- den increase in

A 61-year-old male came to the Physical examination showed a weak

Emergency Department in Karawang general condition, however, airway

General Hospital complaining pain in breathing circulation is within

his left leg a day before admission. normal limits and he is fully

Additionally, the patient felt tingles conscious (compos mentis). His

and bluish in his leg. The pain was blood pressure was 170/100 mmHg,

sudden, especially in the knee area. RR 26x/m, pulse 120 bpm,

In addition, the patient also temperature 36.8°C, and SpO2 97%.

complained of shortness of breath Looks bluish on the left leg as high

accompanied by cough and fever as half thigh. CRT can’t detected in

since 3 days ago. The patient had the left leg and cold.

hypertension, CHF, and underwent Laboratory results showed Hb 13,7

stent angioplasty in 2017. History of g/dL; Ht 41,2%; RBC 4,7 x10 6/uL;

diabetes mellitus (DM) was denied. Platelets 507x103/uL; WBC

The patient admitted that he had 14,93x103/uL; NLR 5,205; ALC

never received the Covid-19 vaccine 2.245; non fasting glucose 150

before. mg/dL; Ur/Cr 58,6/1.58mg/dL; ESR

99 mm/h; CRP reactive; HIV

negative; and PCR SARS-CoV-2

positive. Chest x-ray suggested

inhomogeneous consolidation in

Fig 1. Patient condition on admission bilateral pulmonary inferior zones,

suspect viral pneumonia. X-ray of his

left foot and leg suggested a tests, he was diagnosed with Acute

gangrenous appearance. CT- limb ischemia Rutherford category

Angiography suggested severe distal III and Covid-19. In the ED, the

stenosis of the left femoral artery patient received IVDF normal saline

with complete occlusion its distal 0,9%, ceftriaxone, heparin bolus

aspect. 3.000 unit next 600 unit per hours,

atorvastatin, aspilet, clopidogrel,

captopril, paracetamol, bicnat,

avigan, azitromicin, vitamin D, N-

acetil cysteine. The patient was then

admitted to the hospital on July 12th.

The patient was planned to be

Fig 2. Chest x-ray referred to a hospital that has an

isolation operating room for Covid-

19, but he refused and underwent

debridement with left leg amputation

on August 18th. The patient then was

discharged on August 20th.

Fig 3. CT-Angiography

According to the patient history,

physical examination, and additional

 mainly infects airway cells lining the

alveoli and binds with receptors,

specifically ACE-2 into the host cell.

Glycoprotein within the spike

envelope will bind with a cellular

receptor in ACE2, duplicate its

genetic material then synthesize

proteins essential for generating new

Fig 4. Post-amputation condition virion. Dysregulation of the immune

DISCUSSION system plays role in tissues damage

Coronavirus disease 2019 (COVID- during infection. On the other hand,

19) caused by virus severe acute excessive immune response might

respiratory syndrome coronavirus 2 cause tissue damage. 4

(SARS-CoV-2) is very contagious This virus mainly attacks the

and causes a pandemic recently. The respiratory system. Diagnosis is

main manifestation involves the made based on clinical

respiratory system. Up to July 13th manifestation. Typical signs and

2021, the Indonesian Government symptoms of COVID-19 area acute

reported 2.615.529 confirmed cases, respiratory problems, fever (> 380C),

68.219 deaths, and 2.139.601 cough, and breathing difficulty.

recovered from COVID-19. 2,3 Additionally, patients might have

Pathogenesis has not been explored ageusia, anosmia, nausea, and

in detail. However, SARS-CoV-2 vomiting. About half of the cases

suffer from dyspnea within a week. significantly disturbed compared to

Mean incubation time is 5-6 days healthy individuals and monitoring

with the longest reaching 14 days. coagulation parameters potentially

Severe COVID-19 might cause help identify severe cases earlier.

sepsis, severe pneumonia, ARDS, COVID-19 infection is associated

kidney failure, even death. An X-ray with an increased incidence of

test might show ground-glass opacity thromboembolic events, including

and diffuse pneumonic infiltrate in acute limb ischemia (ALI). ALI

both lung fields. 5,6 might develop even in young and

A recent study reported clinical healthy adults with anticoagulation

characteristics and overall results of prophylaxis. Before COVID-19,

COVID-19 with its effects on the studies had found that the overall

healthcare system. Two studies incidence of ALI had decreased

highlight coagulopathy and its significantly and hypercoagulation

association with a higher mortality was the uncommon cause in a wide

rate. Tang et al found that abnormal population with ALI. 7,8

coagulation profiles, marked with ALI is a vascular emergency

spiking D-dimer and fibrin associated with a high risk for limb

degradation products were loss and death. Most cases result

commonly found in deceased from in situ thrombosis in patients

patients due to COVID-19 with pre-existing peripheral arterial

pneumonia. Han et al showed that disease or those who have undergone

coagulation function was vascular procedures including

stenting and bypass grafts. The other (cool extremity), paresthesia, and

common source is cardioembolic. 9 finally, onset of paralysis.9

The causative mechanism for ALI The clinical classification for ALI as

seems to be a systematic
proposed by Rutherford et al and
inflammatory process triggered by a
subsequently adopted by the Society
massive activation of macrophages
of Vascular Surgery and

that generate a cytokine storm. International Society of

COVID-19 causes elevated cytokine Cardiovascular Surgery, takes into

levels, including but not limited to consideration the clinical findings

tumor necrosis factor-a, IL-1b, IL-6, such as sensory and muscle

weakness and the Doppler indices of

procalcitonin, and interferon g. The
the arterial and venous systems. This
coupling of inflammation and
classification helps to determine
coagulation has also been described
urgency, prognosticate success of
in the literature, with these
limb salvage and guide decision
procedures sharing common
making in terms of therapy
molecular
(►Table1). 10
pathways.10
Acute limb ischemia management in
The typical clinical presentation of
COVID-19 might be harder than
acute limb ischemia is encompassed
expected, due to hypercoagulation.
by “the rule of P’s”: pain,
The patient might receive benefits
pulselessness, pallor, poikilothermia
from unfractionated heparin (UFH)

after prolonged surgery. Bellosta et

 al described 20 patients (18 male)

with ALI associated with COVID-19 disease in COVID-19 was different

for 3 months. Seventeen patients from classic arterial thrombosis. 8

underwent surgical care with COVID-19 patients might present

revascularisation and only 12 with acute non-atherosclerotic

patients succeed (70,6%). The lower thrombosis. Several mechanisms had

success rate from expected might be been suggested to explain those

due to a hypercoagulative state. phenomena. Hyperinflammation

Previous studies had proven that the response was expected to be

pathogenesis of arterial thrombotic responsible for both arterial and

Category Description Clinical finding Doppler signals Prognosis

Sensory Muscle Arterial Venous
Loss weakness
I Viable None None Audible Audible Not immediately
threatened, can
attempt
revascularizatrion
II Threatened
IIa Marginally Minimal None Often Audible Salvageable with
threatened (toes) or inaudible prompt
none revascularization
IIb Immediately More than Mild or Usually Audible Salvageable with
threatened toes, moderate inaudible immediate
associated revascularization
with rest
pain
III Irreversible Profound, Profound, Inaudible Inaudible Major tissue loss or
anesthetic paralysis permanent nerve
(rigor) damage inevitable,
consider amputation
venous thromboembolic events in

Table 1. Rutheford clinical COVID-19 patients. Increased

classification.10
 Rutherford’s class, duration of

D-dimer, fibrinogen, coagulation ischemia, comorbidities, and

factors, acquired antiphospholipid therapy-related risks and outcomes.

antibody and decreased protein C, ►Fig. 5 outlines initial assessment

protein S, antithrombin, also platelet and recommended revascularization

and neutrophil hyperactivation had strategies as endorsed by

been observed. There was also professional societies.9

speculation that direct viral infection The main goals of CLI (Critical

from endothelial cells through ACE- Limb Ischemia) treatments are to

2 preserve

might be the cause of arterial limbs. Revascularization is the

thrombosis in COVID-19. 8 fundamental strategy to preserve

extremities, however, in several

patients, this measure did not system might help identify those

improve with high risk to undergo major

both function and mobility of the amputation. 11

limbs. When revascularization is CONCLUSION

considered, arterial imaging helps COVID-19 is a very infectious

identify the target and mode of disease that causing a pandemic

revascularization. Due to the recently. COVID-19 infection is

limitation of distal arteries imaging associated with an increased

non-invasively, invasive angiography incidence of thromboembolic events,

view regarding the selection of related to the increased mortality

management and should be rate. Acute Limb Ischemia is the

considered before undergoing most severe form of peripheral

amputation. Revascularization might arterial disease, associated with an

be not suitable for all patients, increased risk of limb loss. The main

therefore requiring major purpose of therapy was to maintain

amputation, the functionality of the affected body

including patients with severe arterial parts. Not all patients could be

is commonly done to provide a better managed with revascularization,

disease, infection, or tissue loss that therefore had to undergo major

is impossible to be preserved. Major amputation. Major amputation is an

amputation is a definitive therapy for important choice of treatment for

those cases. Application of grading managing third category of ALI

classification by Rutherford. A
rational and wise approach is needed https://www.who.int/indonesia/n

to make a choice between ews/novel-coronavirus

revascularization and amputation for 4. Gugus Tugas Percepatan

high-risk patients. Penanganan Covid-19. Pedoman

Conflict of Interest Penanganan Cepat Medis dan

The author has no conflict of interest Kesehatan Masyarakat Covid-19

related to this article. di Indonesia. 2020;1–38.

5. Guan WJ, Ni ZY, Hu Y, et al.

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