Vascular Covid Diaries

Arunagiri Viruthagiri, Nedunchezhian Manjini

Consultant Vascular and Endovascular Surgeon, Department of Vascular and Endovascular Surgery, Kauvery Hospital, Trichy, Tamilnadu

Operative Procedure – Mar to Aug

  • Total number of procedures = 120
  • Open procedures = 85
  • Endovascular interventions = 35


Procedures No Description Mortality
Acute limb ischemia 14 Limb salvage – 10
Amputation – 4
Vascular Trauma 8 Limb Salvage – 8
Amputation – None
Peripheral arterial disease angioplasty/stenting 19 Limb Salvage – 18
Amputation – 1
Peripheral arterial disease-bypass 3 Aorobifemoral bypass – 2
Femoropopliteal bypass – 1
Varicose veins – endovenous Laser 10 Complete clinical success. Uneventful Nil
AV fistula and interventions 16 AV fistula-11
Thrombolysis and Permcath insertion- 4
Primary failure – 1.
Graft thrombectomy – failed access
Interventions in DVT 2 IVC filter – 1
Iliac venous stenting – 1
Major amputations 10 Below knee – 8
Above knee – 2
Primary wound healing achieved 9/10
Debridement and minor amputations 32 One proceeded to major amputation Nil


Miscellaneous Procedure No Outcome
Brachial pseudo aneurysm repair Bipolar ligation 1 Limb salvaged
Vascular malformations Complete excision 3 No further bleeding
Renal cell carcinoma with suprahepatic IVC thrombosis Left radical nephrectomy with IVC thrombectomy/splenectomy 1 Complete thrombus clearance. Discharged with no major complications
Acute mesenteric schema Laparotomy with SMA embolectomy and bowel resection 1 Salvaged 120 cm of small bowel and discharged on anticoagulation

Interesting Cases

Case 1: Juxtarenal Aortic Occlusion With Renovascular Hypertension

  • Sixty-nine years old male was referred with episodes of recurrent flash pulmonary oedema
  • Past h/o CABG and TIA
  • BP 220/120. On five antihypertensives
  • Claudication distance of 200 m
  • On examination absent femoral pulses on both sides

On Evaluation

  • Diagnosed to have polycythemia rubra vera – JAK 2 positive.
  • DTPA scan – 25% function in left kidney and 15% in right kidney
  • CT Angio – Juxta renal Aortoiliac occlusion. Left renal artery stenosis. Rt contracted kidney
  • S. Creatinine – 1.5
  • Echo – Moderate LV dysfunction – 35%
  • Carotid doppler – < 50% stenosis

procedure: Aortobifemoral bypass with left renal artery endarterectomy

  • Epidural, central line, arterial line
  • Midline laparotomy
  • Aorto transected and thromboendarterectomy performed
  • Left kidney perfused with custodial solution
  • Aortobifem bypass with 14 × 7 bifurcated dacron

Postoperative Period

  • Had hypotension and drop in Hb requiring reexploration. No major bleeding noted.
  • Had complete heart block – requiring temporary pacing.
  • Nephrologist, cardiologist and anesthetist opinion obtained
  • Developed an AKI with serum creatinine 3.2
  • Gradually made a good recovery with serum creatinine back to 1.1
  • Three months follow up: BP – 130/90 on two antihypertensives. No further chest pain. Good urine output. Able to walk 500 m.

Case 2: Acute Mesenteric Ischemia

  • A 44-year-old male, diabetic and smoker presented with complaints of diffuse abdominal pain which was not responding to any analgesics over past 24 hrs.
  • On examination he had a grossly distended and tender abdomen. CECT abdomen showed a superior mesentric artery embolus with near total occlusion and ischemic bowel loops

Procedure Details

  • Emergency laparotomy, resection of gangrenous small bowel and SMA embolectomy with vein patch angioplasty was done by gastroenterology & vascular team
  • Abdomen was left open as laparostomy for reexploration after 48 h. During reexploration, the remaining small bowel was well vascularised and bowel continuity was restored by jejunocolic anastomosis.
  • Patient recovered well and was discharged on POD 12 with oral anticoagulants. He didn’t have features of short gut syndrome.

Case 3: Posterior dislocation knee with popliteal artery injury

  • 45 year old male with H/o RTA presented with posterior dislocation left knee with tibial plateau fracture and absent pulses
  • CTA showed complete cut-off at midpopliteal artery with reformation of TP trunk



External fixator with interposition graft for popliteal artery – prone position. Fasciotomy


Postop Period

  • Foot warm with palpable PTA pulse
  • RTPCR positive
  • Hence advised to transfer to Kauvery COVID center
  • Discharged AMA and admitted in GH
  • Followed up in GH and doing well

Case 4: Left renal cell CA with suprahepatic IVC thrombosis

Mr. Chellamuthu 39/M presented to Urology Department with upper abdominal pain, loss of appetite and loss of weight for three months duration


Procedure Details

  • Bilateral subcostal incision with median sternotomy (Benz/ Triradiate)
  • Left radical nephrectomy with splenectomy was done. Then mobilisation of infra hepatic IVC and mobilisation of liver was done. Right renal vein and artery were dissected out. On table it was decided to go for complete cardio pulmonary bypass
  • Control taken on the IVC and then it was opened to extract the tumour thrombus. The thrombus was milked down from intra thoracic IVC and was completely extracted in toto
  • Procedure and postoperative period were uneventful. He was discharged on anticoagulants and penicillin prophylaxis

Procedure: Urology, cardiac surgery and vascular team


Case 5: DM/critical limb threatening ischemia

  • 62 year old male was admitted with foot sepsis and systemic sepsis
  • Underwent emergency debridement
  • Sepsis came under control
  • Postop wound was ischemic
  • MRA-Severe infrapopliteal arterial occlusive disease
  • Planned for Infrapopliteal angioplasty

Pre Angioplasty


Post Angioplasty



  • Patient doing well
  • Palpable DP pulse and triphasic flow in peroneal artery
  • Discharged on dual antiplatelets
  • Wound managed with VAC
  • Wound healed after 6 weeks

Case 6: Acute left lower limb ischemia – Aorto iliac thrombosis in COVID 19 positive patient


  • 43 year old farmer presented to the emergency room with sudden onset of pain left leg and inability to feel and move left leg for 48 h.
  • Recently detected DM. Non smoker. No other comorbidities.


  • Acute left lower limb ischemia
  • Rutherford Class 3 ischemia
  • Left Iliac occlusion
  • Source – COVID related.



Emergency bilateral transfemoral embolectomy with four compartment fasciotomy and left through knee amputation


Post OP Period

  • Uneventful
  • Therapeutic dose of LMWH.
  • Wound healthy.
  • Discharged on Day7.
  • 2 week follow up- patient doing well.
  • Counselled for prosthesis.

Strategies with respect to COVID

  • PPE for all members of OT.
  • Minimally used bipolar diathermy.
  • Careful down bleed from iliac arteries to avoid splash
  • Through knee instead of above knee to avoid muscle and bone cutting thereby preventing aerosol generation.
  • Double operator to minimise time.
  • Total duration – 2 h 15 min

Vascular Interventions In Covid Positive Patients

Case No Presentation RT-PCR CT Chest Procedure Outcome Mortality
1 Acute bilateral lower limb ischemia. 4 day old.Class 3 ischemia left leg. Positive Positive CTSS Bilteral transfemoral embolectom y with left through knee amputation One limb salvaged.LIf e saved Nil
2 Acute Rt lower limb ischemia – advanced Positive Positive Conservative -Pancreatitis, CAD,AKI Awaiting below knee amputation Nil
3 Posterior dislocation knee with Popliteal artery injury Positive Negative Ext fixator with Vascular repair Limb salvaged. AMAGH.Doing well. Nil
4 Acute Rt lower limb ischemiaClass 3 ischemia. Positive Negative Right femoral embolectom y with Rt through knee amputation. Doing well.AKi recovered. Currently in hospital.
5 Acute bilateral lowerlimb ischemia- Aortic thrombosis Positive Indetermin ate Bilateral Transfemoral embolectom y Doing well. Normal foot pulses. Ambulating. Currently in hospital.
6 Acute bilateral lowerlimb ischemiaClass2A. Negative.Ig G antibody positive, Positive Conservative managemen t Doing well. Claudicatio n. Nil
7 Acute Rt upper limb ischemia Class 2B Negative Positive Awaiting surgery NA NA
8 Acute Rt Upper limb ischemia Class 3. Positive Positive AMA- Rt Above elbow amputation in Thanjavur. NA NA
9 Acute Rt lower limb ischemia.Class 2A Positive Positive Conservative management. Patient deferred intervention Discharged with claudicatio n. Nil


  • Department of Anesthesiology and Cardiac Anesthesiology.
  • Departemnt of Radiology.
  • Department of Cardiology and Cardiac surgery.
  • Department of General Medicine and Diabetology.
  • Department of Hematology.
  • Department of Gastroenterology.
  • Department of Nephrology and Urology.
  • Department of Intensive Care and ER.
  • Department of Plastic Surgery.
  • Department of Orthopaedics.
  • Medical Administrator of 3 units
  • Nursing Superintendent of 3 units
  • Theatre team of 3 units. Cath team in Heartcity
  • Nursing and Paramedical staff
  • Billing and Management staff
  • Mr. Krishnamoorthy – Physician Assistant.
  • OPD staff – Mrs. Shanthasheela and Mrs. Kanaga