Outcomes of Surgical Revascularization for Acute Limb Ischemia in COVID-19 Patients Compared With a Non-Infected Cohort

Purpose: Below-knee amputation (BKA), either at the time of creation or after use, in patients with severe peripheral arterial disease (PAD) is complicated, with tissue necrosis leading to wound dehiscence with or without bone exposure. Treatment of BKA stump dehiscence with bone exposure, in most of the cases, is associated with eventual more proximal amputation and significant functional impairment. Complex reconstruction surgeries have been described with moderate success.

Materials and Methods: This report presents a case of a patient who was able to retain his BKA stump successfully and avoid a higher amputation using an innovative new multimodal limb preservation approach.

Results: A 67-year-old man with a history of critical limb ischemia and several other cardiovascular comorbidities presented with left BKA stump skin necrosis, wound dehiscence, and osteomyelitis with tibia and fibula exposure. Initially, a PICC line with I.V. antibiotics was started and endovascular revascularization of the distal branches was performed to improve inflow and distal perfusion (stage 1), followed by extensive removal of nonviable tissue (stage 2). Skin defect was estimated to be greater than 150 cm², with extensive tibia and fibula exposure. Then, serial weekly debridement with retaining sutures, combined with negative pressure wound therapy, was performed for 7 weeks to reduce the size of the wound and facilitate secondary intention healing (stage 3). Eventually, the bones were partially covered with new healthy tissue and as such the patient could proceed to the next step of our treatment algorithm. Stage 4 included 4 serial sessions of wound debridement and application of dehydrated amnion/chorion allografts as postsurgical dressings. After 6 months of therapy, the stump was completely healed, and the patient was able to tolerate a prosthesis.

Conclusions: Knee function is critical for prosthetic rehabilitation and as such, preservation of limb length is crucial for the patient’s best possible quality of life. We believe that our proposed multimodal treatment algorithm, together with close patient monitoring, antibiotic treatment. and risk factor modification, could adequately control tissue loss even in severe cases of BKA stump dehiscence with bone exposure, promising favorable functional outcomes.