Analysis of Presentation and Outcomes in Acute Limb Ischemia Patients During COVID-19 State of Emergency.

BACKGROUND: During the COVID-19 pandemic, cardiovascular patients were found to be presenting to hospitals with myocardial infarctions and cerebrovascular accidents at progressed disease states. We noticed a parallel in acute limb ischemia (ALI) patients presenting during Massachusetts' COVID-19 State of Emergency declaration. We question whether patients developed a hesitancy to seek medical attention at hospitals due to fear of COVID-19. Our objective was to compare acuity of ALI, interventions, and limb survival in patients presenting before, during, and after a state of emergency. METHODS: Four timeframes were set to compare patients presenting peri-2020 COVID-19 State of Emergency and patients presenting during a pre-pandemic era at a tertiary, academic institution. A reference period from 2019, Pre-State of Emergency period, State of Emergency period, and Post-State of Emergency period were designated. Patient characteristics, interventions, and outcomes data were collected. Unpaired t-test, ANOVA, and Chi-square statistical analyses were used. RESULTS: A total of 95 patients presenting with ALI were identified. Compared to Reference group, state of emergency group had more patients presenting with Rutherford Class III, 12.9% vs 35%, and less patient presenting with Class I, 45.1% vs 0%, P = .02. State of emergency group had more delayed presentations with ≥6 hours after symptom onset, 45% vs 85%, P = .01. Above-knee amputations were performed in 20% of patients during state of emergency and 31.6% for Post-State of Emergency, vs 6.5% in the Reference group; P = .03. There was no difference in intensive care unit admission, length of stay, or mortality between patients from different groups. CONCLUSION: During a state of emergency, ALI patients were noted to present later from symptom onset, have greater disease severity, and more likely to undergo amputations. We suspect delay in presentation and limb lost to be attributed to reluctance to seek immediate medical attention.

The Progression of Billowing of Endologix AFX2® Abdominal Aortic Aneurysm Device as a Precursor for the Rupture of an Abdominal Aortic Aneurysm.

Despite recent publications indicating billowing (aneurysmal degeneration of the outer fabric material manifesting as a bulging sac of contained contrast due to weakening of the fabric material between the metal struts) as a benign finding, we present a unique case of billowing that resulted in aneurysmal rupture with the AFX2® stent graft (Endologix, Inc., Irvine, CA). AFX2® consists of an inner metallic endoskeleton with multiple metallic struts covered by a polytetrafluoroethylene graft fabric. It allows the flow of blood or contrast beyond the border of the metallic endoskeleton without evidence of endoleak or rupture secondary to the outer cover being anchored to the endoskeleton with polypropylene sutures only at the proximal and distal ends. Our report raises the concern that although billowing may be a relatively common manifestation with Endologix stent grafts, clinicians have to be diligent as the phenomenon may progress to abdominal aortic aneurysm rupture.

Exertional Abdominal Pain as a Rare Presenting Manifestation of Chronic Mesenteric Ischemia from a Single Mesenteric Vessel Stenosis.

We present an atypical manifestation of chronic mesenteric ischemia in a patient with progressively worsening exertional abdominal pain. Imaging modalities revealed significant isolated stenosis of superior mesenteric artery (SMA). Successful angioplasty and stenting of SMA relieved patient's symptoms, thereby confirming the diagnosis of chronic mesenteric ischemia. Exertional abdominal pain may be a unique manifestation of this disease, but when it presents, clinicians should have acute clinical awareness of this diagnosis.