Lower-extremity Arterial Thrombosis Associated with COVID-19 Is Characterized by Greater Thrombus Burden and Increased Rate of Amputation and Death

Background: During the peak of the coronavirus disease 2019 (COVID-19) pandemic, the authors noted an increase in positive lower-extremity CT angiography examinations in patients who presented with leg ischemia. The goal of this study was to determine whether lower-extremity arterial thrombosis was associated with COVID-19 and whether it was characterized by greater severity in these patients. Materials and Methods: In this retrospective propensity score- matched study approved by the institutional review board, 16 patients who tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and who underwent CT angiography of the lower extremities and 32 patients who tested negative for SARS-CoV- 2 observed from January to April 2018, January to April 2019, and January to April 2020 were compared using three scoring systems: two systems including all vessels, with weighting in one system given to more proximal vessels and with weighting in the other system given to more distal vessels, anda third system in which only the common iliac through popliteal arteries were considered. Correlation with presenting symptoms and outcomes was computed. Fisher exact tests were used to compare patients who tested positive for COVID-19 with patients who tested negative for COVID-19 regarding the presence of clots and presenting symptoms. A Mantel-Haenszel test was used to associate outcome of death and/or amputation with COVID-19 adjusted according to history of peripheral vascular disease (PVD). Results: Sixteen patients with confirmed COVID-19 (70 years +/- 14 [standard deviation]; seven women) who underwent CT angiography and 32 propensity score-matched control patients (71 years +/- 15; 16 women) were included. All patients with COVID-19 (100%, 95% confidence interval [CI]: 79%, 100%) had at least one thrombus, and only 69% of control patients(95% CI: 50%, 84%) had thrombi (P =.02). Ninety-four percent of patients with COVID-19 (95% CI: 70%, 99.8%) had proximal thrombi compared with 47% of control patients (95% CI: 29%, 65%) (P< .001). The mean thrombus score using any of the three scoring systems yielded greater scores in patients with COVID-19 (P< .001). Adjusted for history of PVD, death or limb amputation was more common in patients with COVID-19 (odds ratio = 25; 95% CI: 4.3, 147; P< .001). Patients with COVID-19 who presented with symptoms of leg ischemia only were more likely to avoid amputation or death than patients who also presented with pulmonary or systemic symptoms (P =.001). Conclusion: Coronavirus disease 2019 is associated with lower-extremity arterial thrombosis characterized by a greater clot burden and a more dire prognosis. (C) RSNA, 2020