Aortic thrombosis in COVID-19

Case Report: concurrent myocardial and cerebral infarction due to aortic thrombus

Background

Aortic mural thrombus is a rare acute aortic syndrome that can present with embolism to a distal organ. No guidelines or randomized evidence exist to guide therapy for patients with aortic mural thrombus. Cardiac and cerebral embolism is a particularly unusual presentation of aortic thrombus but has significant implications for patient management.

Case summary

We present an unusual case of a young patient with simultaneous embolization of aortic thrombus to the coronary and cerebral vasculature, causing cerebral infarcts and a myocardial infarction. He presented with chest pain, slurred speech, right homonymous hemianopia, and inferior ST-elevation on electrocardiogram (ECG). Bedside echocardiography identified an inferoseptal regional wall motion abnormality. Emergent computerised tomography (CT) brain and aorta showed acute cerebral infarcts and aortic mural thrombus. He was managed medically with anticoagulation and discharged without disability after a period of rehabilitation.

Discussion

This case demonstrates the value of careful clinical assessment in the setting of ST-elevation prior to transferring a patient for invasive angiography, as well as highlighting the role of echocardiography and CT imaging in the diagnosis of acute aortic syndromes. We describe the various management options for aortic mural thrombus, the role of multi-disciplinary decision-making, and our rationale for selecting a strategy of anticoagulation.

Platelet aggregation with various morphologies of neutrophils in arterial thrombus in a patient with Coronavirus disease: a case report

Arterial thromboembolism is a life-threatening condition in COVID-19 patients; however, the mechanism of hypercoagulopathy remains unknown. A 62-year-old man with a history of obesity was diagnosed with COVID-19 pneumonia. After hospitalisation, unfractionated heparin was administered because of increased D-dimer levels; nevertheless, an arterial embolism in the left lower limb developed on the following day. Enhanced computed tomography revealed an occluded left iliac artery and intra-aortic thrombus at the juxtarenal level. Urgent thrombectomy was performed. On post-operative day 6, coumadin was initiated to treat the remaining thrombus. The patient was discharged without any complications. The removed thrombus pathologically presented platelet aggregation and degenerated neutrophils that were in various time axes; some neutrophils had clear margins of nuclear membrane, whereas others had pyknotic and fragment nuclei. We believe that the platelet formation and the neutrophils in several time axes could be key factors in promoting thrombus formation in COVID-19 patients.

Aortic Thrombosis and Ischemic Stroke With Hemorrhagic Conversion in a Patient With Remote COVID-19 Infection: A Treatment Dilemma

Coronavirus disease 2019 (COVID-19) is primarily known to affect the lungs; however, several studies indicate that it can be a multisystem disease. There is documentation detailing different sequelae of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Patients affected with this virus have been seen to develop a hypercoagulable state leading to systemic thrombosis in some cases or embolism leading to catastrophic outcomes in others. Data regarding anticoagulation in these patients is limited. Further research needs to be carried out for management and prophylaxis for patients with COVID-19 at risk of aortic thrombosis. 

We present a case of a middle-aged man with multiple comorbidities and remote COVID-19 infection who came to the emergency room with signs and symptoms worrisome for a cerebrovascular accident (CVA). Brain imaging revealed multiple cortical infarcts suggestive of a cardioembolic etiology. During his hospitalization, he underwent a transesophageal echocardiogram (TEE) that showed a 1x1 cm mobile thrombus in the distal descending aorta. Laboratory workup was negative for any hypercoagulable condition; it was thought that this patient might have a hypercoagulable state post-COVID-19 infection. After a thorough risk vs. benefit discussion, patient was started on apixaban. He remains alive and is doing well in a recent follow-up in our clinic.

Aortic Thrombosis following COVID-19: A Systematic Review

BACKGROUND

 Arterial and venous thromboses associated with the coronavirus disease 2019 (COVID-19) have been well described. These events are caused by a hypercoagulable state due to endotheliopathy and infection-driven coagulopathy. There has been an ever-increasing number of documented cases of aortic thrombosis (AoT) in COVID-19 patients. We conducted a systematic review of current scientific literature to identify and consolidate evidence of AoT in COVID-19 patients.

METHODS

 A systematic review of literature was conducted between March 15, 2020, and May 1, 2021, on PubMed and Cochrane databases. Additionally, a case from our facility was included.

RESULTS

 A total of 38 studies (12 case series and 26 case reports) and a case from our facility describing AoT in 56 COVID-19 patients were included. Patients were aged 64.8 ± 10.5 years, were predominantly male (75%), and had several comorbidities. AoT was symptomatic in 82,14% of patients; however, when D dimers were reported, they were significantly elevated even in otherwise asymptomatic patients. Most patients had no previous history of aortic disease. Thrombosis was described in all parts of the aorta, with several cases reporting multiple locations. The median reported time until development of AoT was 10 days. Peripheral thrombosis occurred in 73.21% of cases, most commonly causing lower limb ischemia. Mortality rate was 30.4%.

CONCLUSIONS

 AoT can occur with no clinical symptoms or as a primary symptom in otherwise asymptomatic COVID-19 patients. D dimers are a highly sensitive diagnostic tool. Diagnosis of this condition prior to development of complications could be instrumental in saving many lives.

COVID-19 and aortic disease: a practical systematic review of the literature on management and outcomes

Since the advent of the 2019 coronavirus (COVID-19) outbreak, vascular specialists have faced dramatic changes in clinical and surgical practice. Although COVID-19 pulmonary signs and symptoms were the most pertinent problems initially, in the long term cardiovascular complications became the most fearsome, with poor outcomes in terms of morbidity and mortality. Algorithms and decision-making procedures have been modified, not only to treat new clinical findings in COVID-19 positive patients, but also to avoid complications related to pulmonary and systemic infections. Additionally, COVID-19 negative patients experienced challenging management, due to hospital crowding, the risk of nosocomial COVID-19 transmission, and pandemic emergencies. In this context, aortic interventions were subject to several difficulties. First, in COVID-19 positive patients, there was the onset of new pathological scenarios including thrombotic manifestations and the subsequent complications. Second, in both COVID-19 negative and positive patients, there was a need to deliver optimal treatment with acceptable perioperative risks, forcing a rethinking of decisionmaking especially in terms of indications for treatments. The aim of this systematic review is to present evidence published on COVID-19 and aortic-related issues, highlighting some challenging aspects regarding management, treatment and outcomes.