Jornal Vascular Brasileiro
http://www.jvb.periodikos.com.br/article/doi/10.1590/1677-5449.200071
Jornal Vascular Brasileiro
Case Report

COVID-19 diagnosis in a patient with critical limb ischemia: complications and clinical outcomes

Diagnóstico de COVID-19 em paciente com isquemia crítica do membro: complicações e desfechos clínicos

Rafael de Athayde Soares; Rafael Salem Vedovello; Samanta Christine Guedes de Medeiros; Celso Zaffani Nunes; Carlos Alberto Sian; Paulo Daenekas de Melo Jorge

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Abstract

Abstract: A 67-year-old male diabetic patient with systemic arterial hypertension was admitted to the emergency department with a necrotic ulcer in the left external malleolus and no palpable popliteal or pedal pulses. Arterial Duplex ultrasound identified femoropopliteal occlusion, with popliteal refilling below the knee and a patent peroneal artery. An endovascular procedure was performed, requiring retrograde access to the popliteal artery to re-establish blood flow and deploy a popliteal stent. Technical success was achieved and the patient underwent debridement of the wound. Two days later, about 48 hours after the operation, the patient began to exhibit respiratory symptoms, with coughing and dyspnea. He immediately underwent a chest CT that identified ground glass opacities, the crazy-paving pattern, and bilateral air bronchogram in the lungs. A reverse transcription – polymerase chain reaction (RT-PCR) test was positive for SARS-Cov-2. The patient was moved to an intensive care unit and put on mechanical ventilation. Both hydroxychloroquine and azithromycin were administered. Despite appropriate treatment, the patient died 4 days after he was diagnosed with COVID-19.

Keywords

COVID-19, critical limb ischemia, endovascular surgery, angioplasty, peripheral occlusive arterial disease, gangrene

Resumo

Resumo: Paciente do sexo masculino, 67 anos, diabético, hipertenso, foi admitido no pronto-socorro com histórico de úlcera necrótica no maléolo externo esquerdo, sem pulsos poplíteos e distais palpáveis. A ultrassonografia Doppler arterial identificou oclusão femoropoplítea, com reenchimento da artéria poplítea infragenicular e perviedade da artéria fibular. Foi realizado procedimento endovascular, com necessidade de acesso retrógrado na artéria poplítea para restabelecer o fluxo sanguíneo e realizar implante de stent poplíteo. O sucesso técnico foi alcançado e, em seguida, o paciente foi submetido ao desbridamento da ferida. No segundo dia, cerca de 48 horas de pós-operatório, o paciente apresentou quadro respiratório com tosse e dispneia. Foi submetido a uma tomografia computadorizada do tórax, que identificou opacidades em vidro fosco e broncograma aéreo bilateralmente nos pulmões, com teste de reverse transcription – polymerase chain reaction (RT-PCR) positivo para SARS-Cov-2. O paciente foi transferido para uma unidade de terapia intensiva, necessitando de ventilação mecânica. Recebeu hidroxicloroquina e azitromicina. Apesar do tratamento em suporte intensivo, o paciente morreu 4 dias após o diagnóstico de COVID-19.
 

Palavras-chave

COVID-19, isquemia crítica, tratamento endovascular, angioplastia, doença arterial obstrutiva periférica, gangrena

References

1 Ruan Q, Yang K, Wang W, Jiang L, Song J. Clinical predictors of mortality due to COVID-19 based on an analysis of data of 150 patients from Wuhan, China. Intensive Care Med. 2020;46(5):846-8. http://dx.doi.org/10.1007/s00134-020-05991-x. PMid:32125452.

2 Shi S, Qin M, Shen B, et al. Association of cardiac injury with mortality in hospitalized patients with COVID-19 in Wuhan, China. JAMA Cardiol. 2020;5(7):802. http://dx.doi.org/10.1001/jamacardio.2020.0950. PMid:32211816.

3 Arentz M, Yim E, Klaff L, et al. Characteristics and outcomes of 21 critically ill patients with COVID-19 in Washington State. JAMA. 2020;323(16):1612. http://dx.doi.org/10.1001/jama.2020.4326. PMid:32191259.

4 Hoffmann M, Kleine-Weber H, Schroeder S, et al. SARS-CoV-2 cell entry depends on ACE2 and TMPRSS2 and is blocked by a clinically proven protease inhibitor. Cell. 2020;181(2):271-280.e8. http://dx.doi.org/10.1016/j.cell.2020.02.052. PMid:32142651.

5 Deng SQ, Peng HJ. Characteristics of and public health responses to the coronavirus disease 2019 outbreak in China. J Clin Med. 2020;9(2):575. http://dx.doi.org/10.3390/jcm9020575. PMid:32093211.

6 Rutherford RB, Baker JD, Ernst C, et al. Recommended standards for reports dealing with lower extremity ischemia: revised version. J Vasc Surg. 1997;26(3):517-38. http://dx.doi.org/10.1016/S0741-5214(97)70045-4. PMid:9308598.

7 Weaver ML, Hicks CW, Canner JK, et al. The Society for Vascular Surgery Wound, Ischemia, and foot Infection (WIfI) classification system predicts wound healing better than direct angiosome perfusion in diabetic foot wounds. J Vasc Surg. 2018;68(5):1473-81. http://dx.doi.org/10.1016/j.jvs.2018.01.060. PMid:29803684.

8 Heffernan DS, Evans HL, Huston JM, et al. Surgical infection society guidance for operative and peri-operative care of adult patients infected by the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2). Surg Infect. 2020;21(4):301-8. http://dx.doi.org/10.1089/sur.2020.101. PMid:32310715.

9 Guan WJ, Ni ZY, Hu Y, et al. China Medical Treatment Expert Group for Covid-19: clinical characteristics of Coronavirus disease 2019 in China. N Engl J Med. 2020;382(18):1708-20. http://dx.doi.org/10.1056/NEJMoa2002032.

10 Tang N, Li D, Wang X, Sun Z. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. J Thromb Haemost JTH. 2020;18(4):844-7. http://dx.doi.org/10.1111/jth.14768. PMid:32073213.

11 Ali H, Daoud A, Mohamed MM, et al. Survival rate in acute kidney injury superimposed COVID-19 patients: a systematic review and meta-analysis. Ren Fail. 2020;42(1):393-7. http://dx.doi.org/10.1080/0886022X.2020.1756323. PMid:32340507.

12 Azkur AK, Akdis M, Azkur D, et al. Immune response to SARS-CoV-2 and mechanisms of immunopathological changes in COVID-19. Allergy. 2020;75(7):1564-81. http://dx.doi.org/10.1111/all.14364. PMid:32396996.

13 Geraldes A, Valdeira ML. Effect of chloroquine on African swine fever virus infection. J Gen Virol. 1985;66(Pt 5):1145-8. http://dx.doi.org/10.1099/0022-1317-66-5-1145. PMid:3998709.

14 Tsai WP, Nara PL, Kung HF, Oroszlan S. Inhibition of human immunodeficiency virus infectivity by chloroquine. AIDS Res Hum Retroviruses. 1990;6(4):481-9. http://dx.doi.org/10.1089/aid.1990.6.481. PMid:1692728.

15 Keyaerts E, Vijgen L, Maes P, Neyts J, Van Ranst M. In vitro inhibition of severe acute respiratory syndrome coronavirus by chloroquine. Biochem Biophys Res Commun. 2004;323(1):264-8. http://dx.doi.org/10.1016/j.bbrc.2004.08.085. PMid:15351731.

16 Vincent MJ, Bergeron E, Benjannet S, et al. Chloroquine is a potent inhibitor of SARS coronavirus infection and spread. Virol J. 2005;2(1):69. http://dx.doi.org/10.1186/1743-422X-2-69. PMid:16115318.

17 Wilson KC, Chotirmall SH, Bai C, Rello J. COVID-19: interim guidance on management pending empirical evidence. New York: American Thoracic Society; 2020 [cited 2020 may 16]. https://www.thoracic.org/covid/covid-19-guidance.pdf

18 Geleris J, Sun Y, Platt J, et al. Observational study of hydroxychloroquine in hospitalized patients with Covid-19. N Engl J Med. 2020;382(25):2411-8. http://dx.doi.org/10.1056/NEJMoa2012410. PMid:32379955.

19 Bikdeli B, Madhavan MV, Jimenez D, et al. COVID-19 and thrombotic or thromboembolic disease: implications for prevention, antithrombotic therapy, and follow-up. J Am Coll Cardiol. 2020;75(23):2950-73. http://dx.doi.org/10.1016/j.jacc.2020.04.031. PMid:32311448.

20 Menezes-Rodrigues FS, Padrão Tavares JG, Pires de Oliveira M, et al. Anticoagulant and antiarrhythmic effects of heparin in the treatment of COVID-19 patients. J Thromb Haemost. 2020;18(8):2073-5. http://dx.doi.org/10.1111/jth.14902. PMid:32408391.

21 Middeldorp S, Coppens M, Van Haaps TF, et al. Incidence of venous thromboembolism in hospitalized patients with COVID-19. J Thromb Haemost. 2020;18(8):1995-2002. http://dx.doi.org/10.1111/jth.14888. PMid:32369666.

22 Athayde Soares R, Matielo MF, Brochado FC No, Martins Cury MV, Marques RC, Sacilotto R. Number of infrapopliteal arteries undergoing endovascular treatment is not associated with the limb salvage rate in patients with critical limb ischemia. J Vasc Surg. 2016;64(5):1344-50. http://dx.doi.org/10.1016/j.jvs.2016.04.020. PMid:27288107.
 


Submitted date:
05/16/2020

Accepted date:
06/29/2020

Sociedade Brasileira de Angiologia e Cirurgia Vascular (SBACV)"> Sociedade Brasileira de Angiologia e Cirurgia Vascular (SBACV)">
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