Operative techniques
Open surgical intervention was performed in the operating room with the patient under locoregional or local anesthesia and intravenous sedation, using 80 U/kg of intravenous heparin at arterial clamping and routine antibiotic prophylaxis. All patients received oxygen support. At the time of the present analysis, no patient had required preemptive intubation because of COVID-19-related pneumonia. In the patients with aortoiliac or femoropopliteal occlusion, a standard groin incision was used to expose the femoral bifurcation. We selectively used a below-the-knee incision to expose the popliteal artery in patients with isolated popliteal-tibial occlusion. Upper limb ischemia was treated through direct open brachial artery exposure. Thromboembolectomy was performed using standard embolectomy catheters (Le Maitre, Burlington, Mass), sized according to the location of the occlusion. In all cases, completion angiography was performed through the surgical access (Fig 2, C). Tibial arteries and/or forearm vessels were approached selectively in cases of distal occlusion. Fasciotomy was not routinely performed. In those with distal occlusion, especially those with the typical aspect of a desert foot, our protocol has been augmented with intra-arterial locoregional thrombolysis using alteplase (Actilyse; Boehringer Ingelheim Italia SpA, Milan, Italy) at 20 mg/20 minutes. The postoperative antithrombotic regimen has been standardized, with the most recent patients receiving an anticoagulation regimen consisting of continuous intravenous heparin infusion. In the case of a less than 80% basal level of antithrombin III, 500 U of antithrombin III was infused for 10 minutes before starting the continuous intravenous heparin to reach an activated partial thromboplastin time of 2.5 seconds. The thrombi retrieved from each patient were sent for histologic evaluation (Fig 2). Postoperative surveillance was performed with physical examinations every hour and full blood panel tests every 8 hours. Transfusions of packed red blood cells were given only if the hemoglobin level had decreased to less than 8 g/dL. An infectious disease specialist evaluated each patient regularly during the entire hospitalization course to optimize the type, dosage, and duration of antibiotic and antiretroviral therapy. At discharge, all patients were given enoxaparin sodium injections (Clexane; Sanofi SpA, Milan, Italy) for home use at a therapeutic dosage. Follow-up and surveillance imaging will include clinical visits with determination of the ankle-brachial index and duplex ultrasound examination at 1, 6, and 12 months after treatment and then annually. Any change in the examination findings or ankle-brachial index or suspicion of a loss of patency will be confirmed using duplex ultrasonography and computed tomography angiography.