A case report of multisite arterial thrombosis in a patient with coronavirus disease 2019 (COVID-19)

Acute Limb Ischemia in COVID-19: A Systematic Review

Numerous studies have reported cases of acute limb ischemia (ALI) in coronavirus disease 2019 (COVID-19), along with a sharp increase of ALI incidence during the COVID-19 pandemic. The objective of this study was to analyze the clinical features, treatment strategies, and outcomes in COVID-19 patients who developed ALI. A systematic search was performed in PubMed, ScienceDirect, and Cochrane to identify relevant articles. Variables of interest included ALI location, ALI and COVID-19 severity, concomitant thrombosis, comorbidities/risk factors, coagulation and inflammatory parameters, therapy, outcome, and cause of death. Data extraction and pooling were conducted by two reviewers. Fifty-six articles with a total of 191 subjects were included in the analysis; 78.5% of the subjects were male; mean age was 64.2 years; 94.2% of cases were ALI de novo; 41.1% of the subjects had ALI stage IIB; 82.7% of ALI occurred in the lower limb. The popliteal artery was the most commonly affected artery (48.2% of subjects); 38.1% of the subjects had severe COVID-19; 11.1% had asymptomatic COVID-19, and 15.9% were post-COVID-19; 50.7% of the subjects had hypertension; 12.0% of the subjects had concomitant thrombosis; 98.1% of the subjects had elevated D-dimer, and 83.3% of the subjects had elevated C-reactive protein; 61.9% of the subjects underwent surgical thromboembolectomy, 21.3% underwent conservative treatment, and 8.1% underwent amputation initially. The overall mortality rate and limb amputation rate were 39.3 and 22.4%, respectively; 67.6% of deaths were due to respiratory failure. Our study supports that COVID-19 is associated with hypercoagulability that may trigger the development of ALI, and that ALI is a possible predictor of poor outcome in COVID-19 patients.

Concomitant acute limb ischemia and myocardial infarction: another challenge of COVID-19's hypercoagulability

The COVID-19, actual pandemic due to SARS COV 2 is associated with numerous thromboembolic complications. Although venous thrombosis including pulmonary embolisms have been widely described, arterial localization seems rarely reported. Acute limb ischemia and myocardial infarction are two major consequences of arterial thrombosis and their concomitant occurrence among COVID-19 patients is extremely rare. It is an evident aspect of hypercoagulability and a real challenge to physicians. We herein describe the management of a 77 years old COVID-19 patient presenting an acute lower limb ischemia with concomitant myocardial infarction. He underwent coronary angiography with subsequent stent placement then was transferred to the operating room where a thrombectomy was performed. The outcome was poor as the cardiogenic shock persisted in addition to a reperfusion syndrome with multiorgan failure.

Infection, inflammation and thrombosis: a review of potential mechanisms mediating arterial thrombosis associated with influenza and severe acute respiratory syndrome coronavirus 2

Thrombosis has long been reported as a potentially deadly complication of respiratory viral infections and has recently received much attention during the global coronavirus disease 2019 pandemic. Increased risk of myocardial infarction has been reported during active infections with respiratory viruses, including influenza and severe acute respiratory syndrome coronavirus 2, which persists even after the virus has cleared. These clinical observations suggest an ongoing interaction between these respiratory viruses with the host's coagulation and immune systems that is initiated at the time of infection but may continue long after the virus has been cleared. In this review, we discuss the epidemiology of viral-associated myocardial infarction, highlight recent clinical studies supporting a causal connection, and detail how the virus' interaction with the host's coagulation and immune systems can potentially mediate arterial thrombosis.

COVID-19 and acute limb ischemia: a systematic review

INTRODUCTION

The main goal of this systematic review is to analyze the outcomes of acute limb ischemia (ALI) in patients suffering from the novel Coronavirus COVID-19 (Sars-Cov-2).

EVIDENCE OF ACQUISITION

A systematic review on MEDLINE and Embase was conducted up to May 15, 2021. All papers were sorted by abstract and full text by two independent authors. Systematic reviews, commentaries, and studies that did not distinguish status of COVID-19 infection were excluded from review. Patient demographics were recorded along with modality of treatment (endovascular and/or surgical). We analyzed 30-day outcomes, including mortality. Primary outcome was to evaluate clinical characteristic of ALI in patients affected by SARS-CoV-2 in term of location of ischemia, treatment options and 30-day outcomes.

EVINDENCE SYNTHESIS

We selected 36 articles with a total of 194 patients. The majority of patients were male (80%) with a median age of 60 years old. The treatment most used was thromboembolectomy (31% of all surgical interventions). A total of 32 patients (19%) were not submitted to revascularization due to critical status. The rate of technical success was low (68%) and mortality rate was high (35%).

CONCLUSIONS

This review confirms that Sars-Cov-2 is associated with a high risk of ALI. Further studies are needed to investigate the association and elucidate potential mechanisms, which may include a hypercoagulable state and hyperactivation of the immune response. Furthermore, management of ALI is not standardized and depends on patient's condition and extension of the thrombosed segment. ALI in COVID-19 patients is associated with high risk of failure of revascularization and perioperative mortality.

Mechanical rotational thrombectomy in long femoropopliteal artery and stent occlusion in COVID-19 patient: Case report

Introduction

Coronavirus disease-19 (COVID-19) has been increasingly associated with thromboembolic complications. COVID-19 infection has a thrombogenic potential for stents. Herein, we report a case of stent thrombosis in diabetic obese patient COVID-19 positive where was previously released a Multilayer Flow Modulator stent (MFM) for large popliteal aneurysm.

Case report

A 78-year-old male was referred to our hospital for fever and acute pain in the left leg. At history, the same patient had endovascular procedure for a large symptomatic popliteal aneurysm, treated through release of three MFM. The pulmonary CT scan showed COVID-19 infection with confirm of rhino-laryngeal swab. Duplex ultrasound and CT-angiography showed complete thrombosis of stents. The treatment consisted of mechanical thrombectomy using an 8Fr catheter Rotarex plus release of Vibahn stent-graft.

Discussion

COVID-19 patients can present arterial occlusion. In literature are not reported cases about thrombosis peripheral stent. Minimally invasive approaches in redo-procedure reduce risk of infection. Rotarex device was used in revascularization of acute and subacute iliac and femoropopliteal arteries. The goal is to have a debulking, to avoid an incomplete deployment of stent-graft. In our precedent experience, MFM and stent-graft to treatment of popliteal aneurism were safe. It is important to monitor these patients for early identification of failure and rapprochement. In this case, the COVID-19 infection was determinant in promoting thrombosis.

Conclusions

COVID-19 increases risk of thrombosis stent. In our experience debulking through Rotarex and stenting, were decisive factors for revascularization and limb salvage.

Massive Arterial Cerebral Thrombosis in a 59-year old Female Patient With Severe COVID-19

Hypercoagulable states characterized by micro- and macro-vascular thrombotic angiopathy have been observed in COVID-19 patients. Although venous thrombotic events have been well described, data on arterial thrombosis (AT) is still insubstantial. We present a case of COVID-19 complicated with massive arterial cerebral thrombosis. Our case is a 59-year old female with history of hypertension who presented to the outpatient clinic in East Jeddah Hospital, Saudi Arabia, with sore throat, cough and arthralgia for two days. She was confirmed to be COVID-19 positive and started on azithromycin and supportive home care. Her condition worsened and she presented nine days later with drowsiness and generalized weakness. At the hospital, she was diagnosed with severe COVID-19 and was started on prophylaxis enoxaparin. She showed progressive worsening of mental function. Her CT brain showed diffuse extensive arterial cerebral thrombosis. She remained unresponsive and showed an abnormal breathing pattern on mechanical ventilation. She died on day 4 after admission.