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Kawabe K, Suhara M, Taniguchi R, Mochizuki Y, Takayama T, Hoshina K. Subacute Limb Ischemia Suspected from COVID-19-Related Arterial Thrombosis Presenting with Local Occlusion Site Tenderness. Ann Vasc Dis 2024; 17:197-200. [PMID: 38919328 PMCID: PMC11196168 DOI: 10.3400/avd.cr.23-00115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 03/14/2024] [Indexed: 06/27/2024] Open
Abstract
A 59-year-old man was admitted to our hospital with severe popliteal fossa pain and mild left calf claudication. He had had an episode of pyrexia and dyspnea approximately 3 weeks prior. Contrast-enhanced computed tomography revealed acute occlusion of the left popliteal artery and multiple infiltration shadows with bilateral multifocal parenchymal consolidation of the lungs, suggesting post-coronavirus disease 2019 (COVID-19) pneumonia. As he had no comorbid risk of cardiogenic embolism or atherosclerosis, we diagnosed him with COVID-19-related arterial thrombosis. COVID-19-related arterial thrombosis should be considered a possible cause of acute limb ischemia, even when ischemic symptoms occur several weeks post infection.
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Affiliation(s)
- Kenshiroh Kawabe
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masamitsu Suhara
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Division of Vascular Surgery, International University of Health and Welfare Mita Hospital, Tokyo, Japan
| | - Ryosuke Taniguchi
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yasuaki Mochizuki
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Toshio Takayama
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Katsuyuki Hoshina
- Division of Vascular Surgery, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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2
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Nana P, Dakis K, Spanos K, Tsolaki V, Karavidas N, Zakynthinos G, Kouvelos G, Giannoukas A, Matsagkas M. COVID-19 related peripheral arterial thrombotic events in intensive care unit and non-intensive care unit patients: A retrospective case series. Vascular 2024; 32:366-373. [PMID: 36395575 PMCID: PMC9679328 DOI: 10.1177/17085381221140159] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/27/2023]
Abstract
OBJECTIVES COVID-19 associated arterial thrombosis has been attributed to multiple inflammation and coagulation mechanisms. The aim of this study was to report the experience of a tertiary center on COVID-19 patients managed for acute peripheral arterial thrombosis. METHODS A single-center case series was conducted, including retrospectively collected data from all COVID-19 patients presenting arterial thrombosis, from March 2020 to February 2022. Intensive care unit (ICU) and non-ICU cases were included. The primary outcomes were mortality, successful revascularization, and amputation at 30 days. RESULTS Twenty patients presented peripheral arterial thrombosis (90% males, mean age 65 years (16-82 years)). Eighteen were diagnosed with the Delta variant and none was previously vaccinated. All cases presented acute lower limb ischemia; in 20% with bilateral involvement. Nine patients were hospitalized in the ward while 11 in the ICU. From the non-ICU cases, five presented Rutherford IIb and four cases, Rutherford's IIa ischemia. Six cases underwent revascularization (67%). Two of them were finally amputated (33%) and two died during hospitalization (33%). Two revascularizations were considered successful (33%). The ICU group presented mainly with Rutherford's III ischemia (54.5%). The mortality in the ICU cohort was 72.7%. Only one patient underwent successful revascularization and two were amputated in this subgroup. Early mortality was 50% for the total cohort while the type of management was not related to mortality. CONCLUSIONS Covid-19 related arterial thrombosis in non-vaccinated population is associated with 50% early mortality; increased up to 72% in the ICU patients. The amputation rate was 20% while only 40% of the revascularizations were considered successful.
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Affiliation(s)
- Petroula Nana
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Konstantinos Dakis
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Konstantinos Spanos
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Vasiliki Tsolaki
- Intensive Care Unit, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Nikitas Karavidas
- Intensive Care Unit, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - George Zakynthinos
- Intensive Care Unit, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - George Kouvelos
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Athanasios Giannoukas
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Miltiadis Matsagkas
- Department of Vascular Surgery, University Hospital of Larissa, Faculty of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
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3
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Eftekhar Z, Haybar H, Mohebbi A, Saki N. Cardiac Complications and COVID-19: A Review of Life-threatening Co-morbidities. Curr Cardiol Rev 2024; 20:1-12. [PMID: 38415433 DOI: 10.2174/011573403x279782240206091322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 12/23/2023] [Accepted: 01/19/2024] [Indexed: 02/29/2024] Open
Abstract
The novel 2019 coronavirus disease (COVID-19) was first reported in the last days of December 2019 in Wuhan, China. The presence of certain co-morbidities, including cardiovascular diseases (CVDs), are the basis for worse outcomes in patients with COVID-19. Relevant English-language literature was searched and retrieved from the Google Scholar search engine and PubMed database up to 2023 using COVID-19, SARS-CoV-2, Heart failure, Myocardial infarction, and Arrhythmia and Cardiac complication as keywords. Increased hemodynamic load, ischemia-related dysfunction, ventricular remodeling, excessive neurohumoral stimulation, abnormal myocyte calcium cycling, and excessive or insufficient extracellular matrix proliferation are associated with heart failure (HF) in COVID-19 patients. Inflammatory reaction due to the excessive release of inflammatory cytokines, leads to myocardial infarction (MI) in these patients. The virus can induce heart arrhythmia through cardiac complications, hypoxia, decreased heart hemodynamics, and remarkable inflammatory markers. Moreover, studies have linked cardiac complications in COVID-19 with poor outcomes, extended hospitalization time, and increased mortality rate. Patients with COVID-19 and CVDs are at higher mortality risk and they should be given high priority when receiving the treatment and intensive care during hospitalization.
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Affiliation(s)
- Zeinab Eftekhar
- Thalassemia & Hemoglobinopathy Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Habib Haybar
- Atherosclerosis Research Center, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | - Alireza Mohebbi
- Department of Hematology and Blood Banking, School of Allied Medical Sciences, Tehran University of Medical Sciences, Tehran, Iran
| | - Najmaldin Saki
- Thalassemia & Hemoglobinopathy Research Center, Health Research Institute, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
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4
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Pawar P, Jha M, Samuel V, Stephen E, George RK. COVID Related Acute Limb Ischaemia: Data from India. Eur J Vasc Endovasc Surg 2023; 66:881-882. [PMID: 37660750 DOI: 10.1016/j.ejvs.2023.08.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 08/15/2023] [Accepted: 08/29/2023] [Indexed: 09/05/2023]
Affiliation(s)
- Pranay Pawar
- Vascular Surgery Unit, Christian Medical College and Hospital, Ludhiana, India, Punjab, India.
| | - Manvendu Jha
- Vascular Surgery Unit, Christian Medical College and Hospital, Ludhiana, India, Punjab, India
| | - Vimalin Samuel
- Vascular Surgery Unit, Christian Medical College and Hospital, Ludhiana, India, Punjab, India
| | - Edwin Stephen
- Vascular Surgery Unit, Christian Medical College and Hospital, Ludhiana, India, Punjab, India
| | - Robbie K George
- Vascular Surgery Unit, Christian Medical College and Hospital, Ludhiana, India, Punjab, India
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5
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Bhatta S, Shrestha E, Sigdel A, Osti N, Upreti P. A Rare Case of Arterial and Venous Thrombosis in COVID-19. Cureus 2023; 15:e49206. [PMID: 38143679 PMCID: PMC10738724 DOI: 10.7759/cureus.49206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2023] [Indexed: 12/26/2023] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has brought attention to the significant risk of thrombotic complications in infected individuals. We present a rare case of a 64-year-old male with COVID-19 who developed bilateral deep vein thrombosis (DVT), pulmonary embolism (PE), and thrombus in the thoracic and abdominal aorta. The patient exhibited common symptoms of COVID-19 and required intensive care unit admission due to respiratory failure. Subsequent investigations revealed thrombi in the lower extremities, pulmonary arteries, and aorta. Prompt anticoagulation therapy was initiated, and vascular surgery consultation was sought. This case highlights the increased risk of venous and arterial thrombotic events in COVID-19 patients and emphasizes the importance of comprehensive management strategies. The interplay of various factors in COVID-19 contributes to a prothrombotic state, necessitating a multi-modal approach to address thrombotic complications. Further research is needed to optimize treatment protocols and improve outcomes for COVID-19 patients with thrombotic complications.
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Affiliation(s)
| | - Elina Shrestha
- Internal Medicine, St. Vincent Medical Center, Bridgeport, USA
| | | | - Narayan Osti
- Surgery, NYC Health and Hospital Harlem, New York City, USA
| | - Prakash Upreti
- Internal Medicine, Rochester Regional Health, New York, USA
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6
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Giannis D, Goldin M, Rahman H, Sison CP, Lesser ML, Ngu S, Tsang J, Qiu M, Sanghani S, Yeh J, Matsagkas M, Arnaoutoglou E, Spyropoulos AC. Risk Factors for Postdischarge Major Thromboembolism and Mortality in Hospitalized Patients with COVID-19 with Cardiovascular Comorbidities: Insights from the CORE-19 Registry. Thromb Haemost 2023; 123:1089-1099. [PMID: 37146648 DOI: 10.1055/a-2087-3003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) is associated with venous and arterial thromboembolism (VTE and ATE) and all-cause mortality (ACM) in hospitalized patients. High-quality data are needed on postdischarge outcomes in patients with cardiovascular disease. OBJECTIVES To analyze outcomes and identify risk factors for ATE, VTE, and ACM in a high-risk subgroup of hospitalized COVID-19 patients with baseline cardiovascular disease. METHODS We investigated postdischarge rates and associated risk factors of ATE, VTE, and ACM in 608 hospitalized COVID-19 patients with coronary artery disease, carotid artery stenosis (CAS), peripheral arterial disease (PAD), or ischemic stroke. RESULTS Through 90 days postdischarge, outcome rates were: ATE 27.3% (10.2% myocardial infarction, 10.1% ischemic stroke, 13.2% systemic embolism, 12.7% major adverse limb event); VTE 6.9% (4.1% deep vein thrombosis, 3.6% pulmonary embolism); composite of ATE, VTE, or ACM 35.2% (214/608). Multivariate analysis showed significant association between this composite endpoint and age >75 years (odds ratio [OR]: 1.90, 95% confidence interval [CI]: 1.22-2.94, p = 0.004), PAD (OR: 3.23, 95% CI: 1.80-5.81, p ≤ 0.0001), CAS (OR: 1.74, 95% CI: 1.11-2.75, p = 0.017), congestive heart failure (CHF) (OR: 1.84, 95% CI: 1.02-3.35, p = 0.044), previous VTE (OR: 3.08, 95% CI: 1.75-5.42, p < 0.0001), and intensive care unit (ICU) admission (OR: 2.93, 95% CI: 1.81-4.75, p < 0.0001). CONCLUSION COVID-19 inpatients with cardiovascular disease experience high rates of ATE, VTE, or ACM through 90 days postdischarge. Age >75 years, PAD, CAS, CHF, previous VTE, and ICU admission are independent risk factors.
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Affiliation(s)
- Dimitrios Giannis
- Institute of Health Systems Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, United States
- Department of Vascular Surgery, University of Thessaly, Larissa, Greece
- Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, New York, New York, United States
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
| | - Mark Goldin
- Institute of Health Systems Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, United States
- Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, New York, New York, United States
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
| | - Husneara Rahman
- Institute of Health Systems Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, United States
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
| | - Cristina P Sison
- Institute of Health Systems Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, United States
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
| | - Martin L Lesser
- Institute of Health Systems Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, United States
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
| | - Sam Ngu
- Institute of Health Systems Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, United States
- Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, New York, New York, United States
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
| | - James Tsang
- Institute of Health Systems Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, United States
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
| | - Michael Qiu
- Institute of Health Systems Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, United States
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
| | - Shreya Sanghani
- Institute of Health Systems Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, United States
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
| | - Jackson Yeh
- Institute of Health Systems Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, United States
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
| | - Miltiadis Matsagkas
- Department of Vascular Surgery, University of Thessaly, Larissa, Greece
- Department of Anesthesiology, University of Thessaly, Larissa, Greece
| | - Eleni Arnaoutoglou
- Department of Vascular Surgery, University of Thessaly, Larissa, Greece
- Department of Anesthesiology, University of Thessaly, Larissa, Greece
| | - Alex C Spyropoulos
- Institute of Health Systems Science, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, United States
- Department of Medicine, Anticoagulation and Clinical Thrombosis Services, Northwell Health at Lenox Hill Hospital, New York, New York, United States
- Department of Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, United States
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Chen YC, Chen CY, Wang AY, Hou SK, Lai KSL, Chou CL, Lin YY, Lin YC, Huang CY. Thromboembolic Presentations among Patients Hospitalized to the Intensive Care Unit for Coronavirus Disease 2019 (COVID-19) - A Northern Taiwan Single Center Experience. ACTA CARDIOLOGICA SINICA 2023; 39:695-708. [PMID: 37720401 PMCID: PMC10499957 DOI: 10.6515/acs.202309_39(5).20230203a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 02/03/2023] [Indexed: 09/19/2023]
Abstract
Coronavirus Disease 2019 (COVID-19) has been associated with a high thromboembolic risk among patients in intensive care units. Asian populations may share a similar thromboembolic risk, but with a higher prevalence of arterial thromboembolism than venous thromboembolism. To clarify this risk in Taiwan, this single-center retrospective study collected 27 consecutive intensive care unit patients with COVID-19 confirmed by polymerase chain reaction, with a median age of 67.6 years (male 81.5%). Twenty-three patients received prophylactic anticoagulation (85.2%), and there were four bleeding events (14.8%). Nine patients had thromboembolism (33.3%), including three with deep vein thrombosis, two with peripheral artery thromboembolism, and four with ischemic stroke. There were no significant clinical differences between the patients with or without thromboembolism. Initial serum ferritin [adjusted odds ratio (OR): 13.19, 95% confidence interval (CI): 1.01-172.07] and peak serum procalcitonin (adjusted OR: 18.93, 95% CI: 1.08-330.91) were associated with a higher risk of thromboembolism. Furthermore, prophylactic anticoagulation (adjusted OR: 0.01, 95% CI: < 0.001-0.55) was associated with a lower risk of thromboembolism. All cases of deep vein thrombosis and one peripheral artery thromboembolism occurred at intravascular catheter locations. No association between thromboembolism and survival was found (age-adjusted hazard ratio: 0.55, 95% CI: 0.10-2.95). In conclusion, the prevalence of COVID-19 thromboembolism among Taiwanese patients in intensive care units was high, even with prophylactic anticoagulation. Serum ferritin and procalcitonin may identify high-risk populations. Prophylactic anticoagulation may reduce the risk of thromboembolism with a manageable bleeding risk. Larger prospective studies are needed to clarify the risk of COVID-19 thromboembolism and its risk factors in the post-Omicron era.
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Affiliation(s)
- Yen-Chou Chen
- Taipei Heart Institute, Taipei Medical University
- Division of Cardiology and Cardiovascular Research Center
| | - Ching-Yi Chen
- Division of Nephrology, Department of Internal Medicine, Taipei Medical University Hospital
- TMU-Research Center of Urology and Kidney, Taipei Medical University, Taipei
| | - An-Yi Wang
- Department of Emergency Medicine, School of Medicine, College of Medicine, Taipei Medical University
- Division of Critical Care Medicine, Department of Critical Care and Emergency Medicine
| | - Sen-Kuang Hou
- Department of Emergency Medicine, School of Medicine, College of Medicine, Taipei Medical University
- Division of Critical Care Medicine, Department of Critical Care and Emergency Medicine
| | - Kevin Shu Leung Lai
- Division of Critical Care Medicine, Department of Critical Care and Emergency Medicine
| | | | - Yun-Yi Lin
- Department of Physical Medicine and Rehabilitation, Taipei Medical University Hospital
- Institute of Health Policy and Management, College of Public Health, National Taiwan University
| | - Yi-Cheng Lin
- Department of Pharmacy, Taipei Medical University Hospital
- School of Pharmacy, College of Pharmacy, Taipei Medical University, Taipei, Taiwan
| | - Chun-Yao Huang
- Taipei Heart Institute, Taipei Medical University
- Division of Cardiology and Cardiovascular Research Center
- Department of Biomedical Sciences and Engineering, National Central University, Taoyuan
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D'Amico R, Wolff T, Richarz S, Gurke L, Isaak A, Mujagic E. A Novel Percutaneous Technique for Aorto-Iliac Thrombectomy without the Risk of Embolization. Bioengineering (Basel) 2023; 10:778. [PMID: 37508805 PMCID: PMC10376630 DOI: 10.3390/bioengineering10070778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/20/2023] [Accepted: 06/26/2023] [Indexed: 07/30/2023] Open
Abstract
Classic surgical thrombectomy of the aorta and iliac arteries through an incision in the groin vessels harbors the risk of embolization to the viscero-renal as well as hypogastric arteries, while percutaneous endovascular thrombectomy techniques can lead to peripheral embolization to the lower limbs. Therefore, we describe a novel, percutaneous technique that tackles the above issues. Furthermore, we also present our initial experience using the technique. The principle of the technique is to percutaneously place large-bore sheaths in the iliac arteries that deliberately occlude the latter to protect the lower limbs from embolization. Through one of these sheaths, over wire Fogarty® catheters can be placed and inflated in the ostia of the coeliac trunk, superior mesenteric artery, renal arteries, and hypogastric arteries as needed. A large thrombectomy balloon catheter is then used to bring any aorto-iliac thrombus into the sheaths, whereafter the thrombus is removed from the sheaths by simply deflating their valves. Additional endovascular procedures of the aorto-iliac branches can be performed as needed. We report nine procedures in 8 patients (4 males and 4 females) with a median age of 63 (53-68.5). Additional endovascular procedures were performed in 6 (66.7%) procedures. All but one procedure were technically successful, and all patients had palpable foot pulses on completion of the procedures, while no patient had clinical signs of peripheral embolization. This technique is a very valid addition to the vascular surgeon's armamentarium when treating aorto-iliac thrombotic events because it is minimally invasive while still protecting against embolization and offering the flexibility to perform a wide range of additional endovascular procedures where needed.
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Affiliation(s)
- Rosalinda D'Amico
- University Hospital of Basel, Spitalstrasse 21, 4031 Basel, Switzerland
- Kantonsspital Aarau, Tellstrasse 25, 5001 Aarau, Switzerland
- Faculty of Medicine, University of Basel, Klingelbergstrasse 61, 4056 Basel, Switzerland
| | - Thomas Wolff
- University Hospital of Basel, Spitalstrasse 21, 4031 Basel, Switzerland
- Faculty of Medicine, University of Basel, Klingelbergstrasse 61, 4056 Basel, Switzerland
| | - Sabine Richarz
- University Hospital of Basel, Spitalstrasse 21, 4031 Basel, Switzerland
- Faculty of Medicine, University of Basel, Klingelbergstrasse 61, 4056 Basel, Switzerland
| | - Lorenz Gurke
- University Hospital of Basel, Spitalstrasse 21, 4031 Basel, Switzerland
- Faculty of Medicine, University of Basel, Klingelbergstrasse 61, 4056 Basel, Switzerland
| | - Andrej Isaak
- Kantonsspital Aarau, Tellstrasse 25, 5001 Aarau, Switzerland
| | - Edin Mujagic
- University Hospital of Basel, Spitalstrasse 21, 4031 Basel, Switzerland
- Faculty of Medicine, University of Basel, Klingelbergstrasse 61, 4056 Basel, Switzerland
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9
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Greistorfer T, Jud P. Clinical characteristics of COVID-19 associated vasculopathic diseases. Thromb J 2023; 21:61. [PMID: 37231476 DOI: 10.1186/s12959-023-00504-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Accepted: 05/17/2023] [Indexed: 05/27/2023] Open
Abstract
Coronavirus disease 19 (COVID-19) has shown to be an infectious disease affecting not only of the respiratory system, but also cardiovascular system leading to different COVID-19-associated vasculopathies. Venous and arterial thromboembolic events have been frequently described among hospitalized patients with COVID-19 and inflammatory vasculopathic changes have also been observed. Several of the reported COVID-19 associated vasculopathies exhibit differences on epidemiology, clinical characteristics and outcome compared to non-COVID-19 types. This review focuses on the epidemiology, clinical, diagnostic and therapeutic characteristics as well as outcome data of COVID-19 associated thromboembolic events and inflammatory vasculopathies, elaborating similarities and differences with non-COVID-19 cohorts.
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Affiliation(s)
- Thiemo Greistorfer
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, Graz, 8036, Austria
| | - Philipp Jud
- Division of Angiology, Department of Internal Medicine, Medical University of Graz, Auenbruggerplatz 15, Graz, 8036, Austria.
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10
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Louis DW, Saad M, Vijayakumar S, Ilyas S, Kokkirala A, Aronow HD. The Cardiovascular Manifestations of COVID-19. Heart Fail Clin 2023; 19:153-161. [PMID: 36863807 PMCID: PMC9973545 DOI: 10.1016/j.hfc.2022.08.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/04/2023]
Abstract
The Coronavirus 2019 (COVID-19) pandemic, caused by the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) virus, has resulted in unprecedented morbidity and mortality worldwide. While COVID-19 typically presents as viral pneumonia, cardiovascular manifestations such as acute coronary syndromes, arterial and venous thrombosis, acutely decompensated heart failure (HF), and arrhythmia are frequently observed. Many of these complications are associated with poorer outcomes, including death. Herein we review the relationship between cardiovascular risk factors and outcomes among patients with COVID-19, cardiovascular manifestations of COVID-19, and cardiovascular complications associated with COVID-19 vaccination.
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Affiliation(s)
- David W. Louis
- Lifespan Cardiovascular Institute, 593 Eddy Street, RIH APC 730, Providence, RI 02903, USA,Department of Medicine, Division of Cardiology, Alpert Medical School of Brown University, 222 Richmond Street, Providence, RI 02903, USA
| | - Marwan Saad
- Lifespan Cardiovascular Institute, 593 Eddy Street, RIH APC 730, Providence, RI 02903, USA,Department of Medicine, Division of Cardiology, Alpert Medical School of Brown University, 222 Richmond Street, Providence, RI 02903, USA
| | - Shilpa Vijayakumar
- Lifespan Cardiovascular Institute, 593 Eddy Street, RIH APC 730, Providence, RI 02903, USA,Department of Medicine, Division of Cardiology, Alpert Medical School of Brown University, 222 Richmond Street, Providence, RI 02903, USA
| | - Suleman Ilyas
- Department of Medicine, Division of Cardiology, Alpert Medical School of Brown University, 222 Richmond Street, Providence, RI 02903, USA
| | - Aravind Kokkirala
- United States Department of Veterans Affairs Providence VA Medical Center, 830 Chalkstone Avenue, Providence, RI 02908, USA
| | - Herbert D. Aronow
- Lifespan Cardiovascular Institute, 593 Eddy Street, RIH APC 730, Providence, RI 02903, USA,Department of Medicine, Division of Cardiology, Alpert Medical School of Brown University, 222 Richmond Street, Providence, RI 02903, USA,Corresponding author. 593 Eddy Street, RIH APC 730, Providence, RI 02903
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11
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Xie B, Semaan DB, Binko MA, Agrawal N, Kulkarni RN, Andraska EA, Sachdev U, Chaer RA, Eslami MH, Makaroun MS, Sridharan N. COVID-associated acute limb ischemia during the Delta surge and the effect of vaccines. J Vasc Surg 2023; 77:1165-1173.e1. [PMID: 36526086 PMCID: PMC9744677 DOI: 10.1016/j.jvs.2022.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Revised: 11/29/2022] [Accepted: 12/02/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Hypercoagulability is common in severe acute respiratory syndrome coronavirus 2 and has been associated with arterial thrombosis leading to acute limb ischemia (ALI). Our objective was to determine the outcomes of concurrent coronavirus disease 2019 (COVID-19) infection and ALI, particularly during the Delta variant surge and the impact of vaccination status. METHODS A retrospective review was performed of patients treated at a single health care system between March 2020 and December 2021 for ALI and recent (<14 days) COVID-19 infection or who developed ALI during hospitalization for the same disease. Patients were grouped by year as well as by pre and post Delta variant emergence in 2021 based on the World Health Organization timeline (January to May vs June to December). Baseline demographics, imaging, interventions, and outcomes were evaluated. A control cohort of all patients with ALI requiring surgical intervention for a 2-year period prior to the pandemic was used for comparison. Primary outcomes were in-hospital mortality and amputation-free survival. Kaplan-Meier survival and Cox proportional hazards analysis were performed. RESULTS Forty acutely ischemic limbs were identified in 36 patients with COVID-19, the majority during the Delta surge (52.8%) and after the wide availability of vaccines. The rate of COVID-19-associated ALI, although low overall, nearly doubled during the Delta surge (0.37% vs 0.20%; P = .09). Intervention (open or endovascular revascularization vs primary amputation) was performed on 31 limbs in 28 individuals, with the remaining eight treated with systemic anti-coagulation. Postoperative mortality was 48%, and overall mortality was 50%. Major amputation following revascularization was significantly higher with COVID-19 ALI (25% vs 3%; P = .006) compared with the pre-pandemic group. Thirty-day amputation-free survival was significantly lower (log-rank P < .001). COVID-19 infection (adjusted hazard ratio, 6.2; P < .001) and age (hazard ratio, 1.1; P = .006) were associated with 30-day amputation in multivariate analysis. Severity of COVID-19 infection, defined as vasopressor usage, was not associated with post-revascularization amputation. There was a higher incidence of re-thrombosis in the latter half of 2021 with the Delta surge, as reintervention for recurrent ischemia of the same limb was more common than our previous experience (21% vs 0%; P = .55). COVID-19-associated limb ischemia occurred almost exclusively in non-vaccinated patients (92%). CONCLUSIONS ALI observed with Delta appears more resistant to standard therapy. Unvaccinated status correlated highly with ALI occurrence in the setting of COVID-19 infection. Information of limb loss as a COVID-19 complication among non-vaccinated patients may help to increase compliance.
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Affiliation(s)
- Bowen Xie
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA.
| | - Dana B Semaan
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Mary A Binko
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | | | - Rohan N Kulkarni
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Elizabeth A Andraska
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Ulka Sachdev
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Rabih A Chaer
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Mohammad H Eslami
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Michel S Makaroun
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Natalie Sridharan
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA
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12
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Thakur A. Shedding Lights on the Extracellular Vesicles as Functional Mediator and Therapeutic Decoy for COVID-19. Life (Basel) 2023; 13:life13030840. [PMID: 36983995 PMCID: PMC10052528 DOI: 10.3390/life13030840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/08/2023] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
COVID-19 is an infectious disease caused by the novel coronavirus (SARS-CoV-2) that first appeared in late 2019 and has since spread across the world. It is characterized by symptoms such as fever, cough, and shortness of breath and can lead to death in severe cases. To help contain the virus, measures such as social distancing, handwashing, and other public health measures have been implemented. Vaccine and drug candidates, such as those developed by Pfizer/BioNTech, AstraZeneca, Moderna, Novavax, and Johnson & Johnson, have been developed and are being distributed worldwide. Clinical trials for drug treatments such as remdesivir, dexamethasone, and monoclonal antibodies are underway and have shown promising results. Recently, exosomes have gained attention as a possible mediator of the COVID-19 infection. Exosomes, small vesicles with a size of around 30-200 nm, released from cells, contain viral particles and other molecules that can activate the immune system and/or facilitate viral entry into target cells. Apparently, the role of exosomes in eliciting various immune responses and causing tissue injury in COVID-19 pathogenesis has been discussed. In addition, the potential of exosomes as theranostic and therapeutic agents for the treatment of COVID-19 has been elaborated.
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Affiliation(s)
- Abhimanyu Thakur
- Ben May Department for Cancer Research, Pritzker School of Molecular Engineering, University of Chicago, Chicago, IL 60637, USA
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13
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Candeloro M, Schulman S. Arterial Thrombotic Events in Hospitalized COVID-19 Patients: A Short Review and Meta-Analysis. Semin Thromb Hemost 2023; 49:47-54. [PMID: 35793687 DOI: 10.1055/s-0042-1749661] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
It is well established that the risk of venous thromboembolism is high in coronavirus disease 19 (COVID-19). The frequency of arterial thromboembolic events (ATEs) in hospitalized patients with COVID-19 is unclear, as is the magnitude of these events in comparison with other infections. We searched MEDLINE from February 2020 to February 2022 for prospective or retrospective cohort studies and randomized clinical trials that reported the number of acute myocardial infarction (AMI), acute ischemic stroke (AIS), acute limb ischemia (ALI), or other ATE as defined by the original authors in hospitalized patients with COVID-19. The pooled frequencies were calculated through meta-analysis using random effects model with logit transformation and presented with relative 95% prediction intervals (95% PI). We retrieved a total of 4,547 studies, 36 of which (28 retrospective cohorts, five prospective cohorts and three randomized trials) were finally included in our analysis. The resulting cohort counted 100,949 patients, 2,641 (2.6%) of whom experienced ATE. The pooled ATE frequency was 2.0% (95% PI, 0.4-9.6%). The pooled ATE frequency for AMI, AIS, ALI, and other ATE was 0.8% (95% PI, 0.1-8.1%), 0.9% (95% PI, 0.3-2.9%), 0.2% (95% PI, 0.0-4.2%), and 0.5% (95% PI, 0.1-3.0%), respectively. In comparison with the ATE incidence reported in three studies on non-COVID viral pneumonia, we did not detect a significant difference from the results in our analysis. In conclusion, we found a non-negligible proportion of ATE in patients hospitalized for COVID-19. Our results are similar to those found in hospitalized patients with influenza or with non-COVID viral pneumonia.
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Affiliation(s)
- Matteo Candeloro
- Department of Innovative Technologies in Medicine and Dentistry, "G. D'Annunzio" University, Chieti, Italy.,Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Sam Schulman
- Department of Medicine, Thrombosis and Atherosclerosis Research Institute, McMaster University, Hamilton, Ontario, Canada.,Department of Obstetrics and Gynecology, I.M. Sechenov First Moscow State Medical University, Moscow, Russia
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14
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Gjonbalaj N, Uka S, Olluri E, Sulovari A, Vishaj M, Kamberi L, Berisha H, Gjonbalaj E. Renal artery thrombosis as a long-term complication of COVID-19. Radiol Case Rep 2023; 18:260-265. [PMID: 36345461 PMCID: PMC9631237 DOI: 10.1016/j.radcr.2022.10.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 10/03/2022] [Accepted: 10/08/2022] [Indexed: 11/05/2022] Open
Abstract
Coronavirus disease 2019 (COVID-19) has been extensively associated with microvascular and macrovascular thrombosis. Several reports have demonstrated a link between COVID-19 and pulmonary embolism, deep vein thrombosis, myocardial infarction, stroke, and aortic thrombosis. Renal artery thrombosis is of special interest because of its life-threatening consequences, such as acute kidney injury and renal infarction. We present a case of left renal artery thrombosis as a long-term complication of COVID-19. Moreover, we demonstrate the effectiveness of interventional radiology to regain vascularization of the affected kidney.
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15
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Cunha JC, Cruz AJ, Madureira B, Martins Y, Sarmento G. Acute Aortic Syndrome in a patient with COVID-19. Arch Clin Cases 2023; 10:47-49. [PMID: 37056951 PMCID: PMC10088050 DOI: 10.22551/2023.38.1001.10239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/15/2023] Open
Abstract
The global effects of the COVID-19 pandemic make it of the utmost importance to comprehend its mechanisms and define strategies for the most effective approach possible. The SARS-CoV-2 virus can be responsible for the induction of a hypercoagulable state, which can trigger vascular phenomena of venous etiology, specifically deep venous thrombosis or pulmonary embolism. Arterial thrombotic events associated with COVID-19 have also been described in the medical literature, although less frequently. In this paper the authors report the case of a 66-year-old man who was diagnosed with an Acute Aortic Syndrome, specifically an intramural thrombus on the aortic arch, while he was still infected with the virus. Anticoagulation with low weight molecular heparin was initiated and the patient was admitted at the Internal Medicine ward for a conservative therapeutic approach. The thrombus remained stable on a serial imaging evaluation; therefore, the patient was discharged with oral anticoagulation with subsequent follow-up in the outpatient clinic. This case describes a rare and potentially serious complication of COVID-19, which highlights how broad its clinical spectrum can be, affecting systems other than the pulmonary.
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Affiliation(s)
- João Campos Cunha
- Entre o Douro e Vouga Hospital Center, Santa Maria da Feira, Portugal
- Correspondence: João Campos Cunha, Entre o Douro e Vouga Hospital Center, R. Dr. Cândido Pinho 5, 4520-211 Santa Maria da Feira, Portugal.
| | - António José Cruz
- Entre o Douro e Vouga Hospital Center, Santa Maria da Feira, Portugal
- Infectious Diseases Department, São João Hospital and University Center, Porto, Portugal
| | - Beatriz Madureira
- Entre o Douro e Vouga Hospital Center, Santa Maria da Feira, Portugal
| | - Yolanda Martins
- Entre o Douro e Vouga Hospital Center, Santa Maria da Feira, Portugal
| | - Gonçalo Sarmento
- Entre o Douro e Vouga Hospital Center, Santa Maria da Feira, Portugal
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16
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Platelet dysfunction and thrombus instability in flow conditions in patients with severe COVID-19. Thromb Res 2023; 221:137-148. [PMID: 36376109 PMCID: PMC9642035 DOI: 10.1016/j.thromres.2022.11.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 10/21/2022] [Accepted: 11/04/2022] [Indexed: 11/09/2022]
Abstract
Severe COVID-19 has been associated with a high rate of thrombotic events but also of bleeding events, particularly when the level of prophylactic anticoagulation was increased. Data on the contribution of platelets to these thrombotic events are discordant between reports, while the involvement of platelets in bleeding events has never been investigated. The objective of the present study was to assess platelet function during the first week of ICU hospitalization in patients with severe COVID-19 pneumonia. A total of 35 patients were prospectively included and blood samples were drawn on day (D) 0, D2 and D7. COVID-19 pneumonia was severe with a median PaO2/FiO2 ratio of 91 [68-119] on D0. Platelets from these patients showed evidence of pre-activation and exhaustion with a significant reduction in the surface expression of GPVI, GPIb and GPIIbIIIa, together with a decrease in serotonin content. Platelets from patients with severe COVID-19 were hyporesponsive with a reduced maximal aggregation response to several platelet agonists and decreased adhesion to immobilized fibrinogen. Aggregation of washed platelets and plasma substitution experiments indicated that a plasma factor was at least partially responsible for this hyporeactivity of platelets. Blood flow experiments showed that severe COVID-19 platelets formed smaller, less stable aggregates on a collagen-coated surface, which could explain why some patients develop bleeding events. These findings should prompt us to carefully evaluate the risks and benefits of high-dose prophylactic anticoagulation, and to decrease the level of anticoagulation once the initial phase of the disease has resolved. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT04359992.
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17
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Uzun G, Althaus K, Hammer S, Bakchoul T. Assessment and Monitoring of Coagulation in Patients with COVID-19: A Review of Current Literature. Hamostaseologie 2022; 42:409-419. [PMID: 35477118 DOI: 10.1055/a-1755-8676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Coagulation abnormalities are common in patients with COVID-19 and associated with high morbidity and mortality. It became a daily challenge to navigate through these abnormal laboratory findings and deliver the best possible treatment to the patients. The unique character of COVID-19-induced coagulopathy necessitates not only a dynamic follow-up of the patients in terms of hemostatic findings but also the introduction of new diagnostic methods to determine the overall function of the coagulation system in real time. After the recognition of the high risk of thromboembolism in COVID-19, several professional societies published their recommendations regarding anticoagulation in patients with COVID-19. This review summarizes common hemostatic findings in COVID-19 patients and presents the societal recommendations regarding the use of coagulation laboratory findings in clinical decision-making. Although several studies have investigated coagulation parameters in patients with COVID-19, the methodological shortcomings of published studies as well as the differences in employed anticoagulation regimens that have changed over time, depending on national and international guidelines, limit the applicability of these findings in other clinical settings. Accordingly, evidence-based recommendations for diagnostics during acute COVID-19 infection are still lacking. Future studies should verify the role of coagulation parameters as well as viscoelastic methods in the management of patients with COVID-19.
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Affiliation(s)
- Günalp Uzun
- Center for Clinical Transfusion Medicine, University Hospital of Tuebingen, Tuebingen, Germany
| | - Karina Althaus
- Center for Clinical Transfusion Medicine, University Hospital of Tuebingen, Tuebingen, Germany.,Medical Faculty of Tuebingen, Institute for Clinical and Experimental Transfusion Medicine, Tuebingen, Germany
| | - Stefanie Hammer
- Center for Clinical Transfusion Medicine, University Hospital of Tuebingen, Tuebingen, Germany
| | - Tamam Bakchoul
- Center for Clinical Transfusion Medicine, University Hospital of Tuebingen, Tuebingen, Germany.,Medical Faculty of Tuebingen, Institute for Clinical and Experimental Transfusion Medicine, Tuebingen, Germany
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18
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Urano T, Yasumoto A, Yokoyama K, Horiuchi H, Morishita E, Suzuki Y. COVID-19 and Thrombosis: Clinical Aspects. Curr Drug Targets 2022; 23:1567-1572. [PMID: 36200150 DOI: 10.2174/1389450123666221005092350] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 08/30/2022] [Accepted: 09/09/2022] [Indexed: 01/25/2023]
Abstract
In coronavirus disease 2019 (COVID-19), thrombus formation is related to the pathogenesis of acute respiratory distress syndrome (ARDS) and the progression of clinical symptoms. Severe damage to vascular endothelial cells and the associated cytokine storm after SARS-CoV-2 infection cause thrombogenesis and contribute to the development of more severe and unique thromboses compared to other infectious diseases. Thromboses occur more often in critically ill patients. In addition to pulmonary thromboembolism (PE) and deep vein thrombosis, acute myocardial infarction, peripheral arterial thrombosis, and aortic thrombosis have also been reported. In PE, thrombi develop in both pulmonary arteries and alveolar capillaries. These, together with intraalveolar fibrin deposition, interfere with effective gaseous exchange in the lungs and exacerbate the clinical symptoms of ARDS in patients with COVID-19. Pharmacological thromboprophylaxis is recommended for all hospitalized patients to prevent both thrombosis and aggravation of ARDS, and other organ failures. Although the pediatric population is mostly asymptomatic or develops mild disease after SARS-CoV-2 infection, a new inflammatory disorder affecting the cardiovascular system, multisystem inflammatory syndrome in children (MIS-C), has been reported. Similar to Kawasaki disease, acute myocarditis, coronary vasculitis, and aneurysms are typically seen in MISC, although these two are now considered distinct entities. A similar acute myocarditis is also observed in young male adults, in which a hyperinflammatory state after SARS-CoV-2 infection seems to be involved. Several side effects following vaccination against COVID-19 have been reported, including vaccine-induced immune thrombotic thrombocytopenia and acute myocarditis. Although these could be serious and life-threatening, the cases are very rare, thus, the benefits of immunization still outweigh the risks.
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Affiliation(s)
- Tetsumei Urano
- Department of Medical Physiology, Hamamatsu University School of Medicine, Hamamatsu, Japan.,Shizuoka Graduate University of Public Health, Shizuoka, Japan
| | - Atsushi Yasumoto
- Department of Hematology, Faculty of Medicine, Hokkaido University, Sappero, Japan
| | - Kenji Yokoyama
- Department of Hematology/Oncology, Tokai University, Tokyo, Japan
| | - Hisanori Horiuchi
- Department of Molecular and Cellular Biology, Institute of Development, Aging and Cancer, Tohoku University, Sendai, Japan
| | - Eriko Morishita
- Department of Clinical Laboratory Sciences, Institute of Medical, Pharmaceutical and Health Sciences, Faculty of Health Sciences, Kanazawa University, Kanazawa, Japan
| | - Yuko Suzuki
- Department of Medical Physiology, Hamamatsu University School of Medicine, Hamamatsu, Japan
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19
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Fuchsberger S, Bloch-Infanger C, Mang G. [Livid Fingers after Respiratory Infection]. PRAXIS 2022; 111:947-950. [PMID: 36475364 DOI: 10.1024/1661-8157/a003941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Livid Fingers after Respiratory Infection Abstract. A 53-year-old patient fell ill with SARS-CoV-2. She suffered from cough, headache and slight exertional dyspnoea. She was hospitalized for a short time as the dyspnoea increased. Two weeks after the first respiratory symptoms, the patient developed painful livid discoloration of the left terminal phalanges I-III. An occlusion of the arteria princeps pollicis and the arteria digitalis communis/propria of the left fingers II and III could be documented in the angiography. In addition to short-term lysis therapy with alteplase, the patient was therapeutically anticoagulated and received aspirin. An ilomedin (iloprost) therapy was carried out.
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Affiliation(s)
| | | | - Georg Mang
- Innere Medizin Kantonsspital Uri, Schweiz
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20
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Borczuk AC, Yantiss RK. The pathogenesis of coronavirus-19 disease. J Biomed Sci 2022; 29:87. [PMID: 36289507 PMCID: PMC9597981 DOI: 10.1186/s12929-022-00872-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 10/20/2022] [Indexed: 01/08/2023] Open
Abstract
Severe acute respiratory syndrome-associated coronavirus-2 (SARS-CoV-2) is the causal agent of coronavirus disease-2019 (COVID-19), a systemic illness characterized by variably severe pulmonary symptoms, cardiac conduction abnormalities, diarrhea, and gastrointestinal bleeding, as well as neurologic deficits, renal insufficiency, myalgias, endocrine abnormalities, and other perturbations that reflect widespread microvascular injury and a pro-inflammatory state. The mechanisms underlying the various manifestations of viral infection are incompletely understood but most data suggest that severe COVID-19 results from virus-driven perturbations in the immune system and resultant tissue injury. Aberrant interferon-related responses lead to alterations in cytokine elaboration that deplete resident immune cells while simultaneously recruiting hyperactive macrophages and functionally altered neutrophils, thereby tipping the balance from adaptive immunity to innate immunity. Disproportionate activation of these macrophages and neutrophils further depletes normal activity of B-cells, T-cells, and natural killer (NK) cells. In addition, this pro-inflammatory state stimulates uncontrolled complement activation and development of neutrophil extracellular traps (NETS), both of which promote the coagulation cascade and induce a state of “thrombo-inflammation”. These perturbations have similar manifestations in multiple organ systems, which frequently show pathologic findings related to microvascular injury and thrombosis of large and small vessels. However, the pulmonary findings in patients with severe COVID-19 are generally more pronounced than those of other organs. Not only do they feature inflammatory thromboses and endothelial injury, but much of the parenchymal damage stems from failed maturation of alveolar pneumocytes, interactions between type 2 pneumocytes and non-resident macrophages, and a greater degree of NET formation. The purpose of this review is to discuss the pathogenesis underlying organ damage that can occur in patients with SARS-CoV-2 infection. Understanding these mechanisms of injury is important to development of future therapies for patients with COVID-19, many of which will likely target specific components of the immune system, particularly NET induction, pro-inflammatory cytokines, and subpopulations of immune cells.
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Affiliation(s)
- Alain C. Borczuk
- grid.512756.20000 0004 0370 4759Department of Pathology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Greenvale, NY USA
| | - Rhonda K. Yantiss
- grid.5386.8000000041936877XDepartment of Pathology and Laboratory Medicine, Weill Cornell Medicine, 525 East 68th Street, New York, NY 10065 USA
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21
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Soroa G, Álvarez A, Monge I, Navarro D, Roca O. Osteonecrosis and Osteomyelitis of the Proximal Third of Tibia as a Late Sequela of COVID-19: A Case Report. PLASTIC AND AESTHETIC NURSING 2022; 42:190-196. [PMID: 36469389 DOI: 10.1097/psn.0000000000000458] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Coronavirus disease was first described as an identified syndrome in December 2019 (COVID-19). Since then, a global pandemic has taken place and the disease has repeatedly been associated with thromboembolic complications, most of which are venous, but may also occur at the arterial level, even in patients receiving thromboprophylaxis. To date, only medium- and large-caliber vessels have been affected by arterial thrombosis secondary to COVID-19. This article describes the case of a 60-year-old woman with a prior severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2) infection who developed multiple bone infarcts, complicated by secondary osteomyelitis. The patient underwent multiple surgical debridements and received a variety of antibiotics before the correct diagnosis was made and a multidisciplinary surgery was planned that provided coverage with a medial gastrocnemius flap. At 5-months follow-up, the patient had recovered well without any clinical evidence of infection or other complications. To the best of our knowledge, this is the first known case of a bone infarct complicated with a secondary osteomyelitis occurring in a patient having suffered a previous SARS-CoV-2 infection. We postulate as our main hypothesis that the prothrombogenic state secondary to SARS-CoV-2 infection may have contributed to thrombosis of small-caliber vessels, in our patient the arteria nutricia tibialis, triggering bone infarcts and a secondary infection with Staphylococcus aureus .
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Affiliation(s)
- Gonzalo Soroa
- Gonzalo Soroa, MD, is a plastic, reconstructive, and aesthetic surgery resident physician, Son Espases University Hospital, Palma de Mallorca, Spain
- Adela Álvarez, MD, is a plastic, reconstructive, and aesthetic surgery resident physician, Son Espases University Hospital, Palma de Mallorca, Spain
- Iván Monge, MD, is a plastic, reconstructive, and aesthetic surgery attending physician, Son Espases University Hospital, Palma de Mallorca, Spain
- Daniel Navarro, MD, is a plastic, reconstructive, and aesthetic surgery resident physician, Son Espases University Hospital, Palma de Mallorca, Spain
- Oriol Roca, MD, is a plastic, reconstructive, and aesthetic surgery attending physician, Son Espases University Hospital, Palma de Mallorca, Spain
| | - Adela Álvarez
- Gonzalo Soroa, MD, is a plastic, reconstructive, and aesthetic surgery resident physician, Son Espases University Hospital, Palma de Mallorca, Spain
- Adela Álvarez, MD, is a plastic, reconstructive, and aesthetic surgery resident physician, Son Espases University Hospital, Palma de Mallorca, Spain
- Iván Monge, MD, is a plastic, reconstructive, and aesthetic surgery attending physician, Son Espases University Hospital, Palma de Mallorca, Spain
- Daniel Navarro, MD, is a plastic, reconstructive, and aesthetic surgery resident physician, Son Espases University Hospital, Palma de Mallorca, Spain
- Oriol Roca, MD, is a plastic, reconstructive, and aesthetic surgery attending physician, Son Espases University Hospital, Palma de Mallorca, Spain
| | - Iván Monge
- Gonzalo Soroa, MD, is a plastic, reconstructive, and aesthetic surgery resident physician, Son Espases University Hospital, Palma de Mallorca, Spain
- Adela Álvarez, MD, is a plastic, reconstructive, and aesthetic surgery resident physician, Son Espases University Hospital, Palma de Mallorca, Spain
- Iván Monge, MD, is a plastic, reconstructive, and aesthetic surgery attending physician, Son Espases University Hospital, Palma de Mallorca, Spain
- Daniel Navarro, MD, is a plastic, reconstructive, and aesthetic surgery resident physician, Son Espases University Hospital, Palma de Mallorca, Spain
- Oriol Roca, MD, is a plastic, reconstructive, and aesthetic surgery attending physician, Son Espases University Hospital, Palma de Mallorca, Spain
| | - Daniel Navarro
- Gonzalo Soroa, MD, is a plastic, reconstructive, and aesthetic surgery resident physician, Son Espases University Hospital, Palma de Mallorca, Spain
- Adela Álvarez, MD, is a plastic, reconstructive, and aesthetic surgery resident physician, Son Espases University Hospital, Palma de Mallorca, Spain
- Iván Monge, MD, is a plastic, reconstructive, and aesthetic surgery attending physician, Son Espases University Hospital, Palma de Mallorca, Spain
- Daniel Navarro, MD, is a plastic, reconstructive, and aesthetic surgery resident physician, Son Espases University Hospital, Palma de Mallorca, Spain
- Oriol Roca, MD, is a plastic, reconstructive, and aesthetic surgery attending physician, Son Espases University Hospital, Palma de Mallorca, Spain
| | - Oriol Roca
- Gonzalo Soroa, MD, is a plastic, reconstructive, and aesthetic surgery resident physician, Son Espases University Hospital, Palma de Mallorca, Spain
- Adela Álvarez, MD, is a plastic, reconstructive, and aesthetic surgery resident physician, Son Espases University Hospital, Palma de Mallorca, Spain
- Iván Monge, MD, is a plastic, reconstructive, and aesthetic surgery attending physician, Son Espases University Hospital, Palma de Mallorca, Spain
- Daniel Navarro, MD, is a plastic, reconstructive, and aesthetic surgery resident physician, Son Espases University Hospital, Palma de Mallorca, Spain
- Oriol Roca, MD, is a plastic, reconstructive, and aesthetic surgery attending physician, Son Espases University Hospital, Palma de Mallorca, Spain
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22
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Chen YC, Huang CP, Lin TM, Huang CY. Severe Digital Ischemia Associated with Upper Limb Arterial Thrombosis and Raynaud's Phenomenon in a Patient with Severe Acute Respiratory Syndrome Coronavirus 2 Infection. ACTA CARDIOLOGICA SINICA 2022; 38:650-652. [PMID: 36176367 PMCID: PMC9479058 DOI: 10.6515/acs.202209_38(5).20220330d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 03/30/2022] [Indexed: 01/24/2023]
Affiliation(s)
- Yen-Chou Chen
- Taipei Heart Institute, Taipei Medical University;
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Division of Cardiology and Cardiovascular Research Center, Taipei Medical University Hospital
| | - Chien-Po Huang
- Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University
| | - Tzu-Min Lin
- Division of Rheumatology, Immunology and Allergy, Department of Internal Medicine, Taipei Medical University Hospital;
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Division of Allergy, Immunology and Rheumatology, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei
| | - Chun-Yao Huang
- Taipei Heart Institute, Taipei Medical University;
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Division of Cardiology and Cardiovascular Research Center, Taipei Medical University Hospital;
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Department of Biomedical Sciences and Engineering, National Central University, Taoyuan, Taiwan
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23
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Thachil J, Favaloro EJ, Lippi G. D-dimers-"Normal" Levels versus Elevated Levels Due to a Range of Conditions, Including "D-dimeritis," Inflammation, Thromboembolism, Disseminated Intravascular Coagulation, and COVID-19. Semin Thromb Hemost 2022; 48:672-679. [PMID: 35803265 DOI: 10.1055/s-0042-1748193] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
D-dimers reflect a breakdown product of fibrin. The current narrative review outlines how D-dimers can arise in normal individuals, as well as in patients suffering from a wide range of disease states. D-dimers in normal individuals without evident thrombosis can arise from background fibrinolytic activity in various tissues, including kidney, mammary and salivary glands, which ensures smooth flow of arising fluids where any blood contamination could be immediately lysed. In addition, healthy individuals can also regularly sustain minor injuries, often unbeknown to them, and wound healing follows clot formation in these situations. D-dimers can also arise in anxiety and following exercise, and are also markers of inflammation. Lung inflammation (triggered by microbes or foreign particles) is perhaps also particularly relevant, since the hemostasis system and fibrinolysis help to trap and remove such debris. Lung inflammation in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) may contribute to D-dimer levels additive to thrombosis in patients with COVID-19 (coronavirus disease 2019). Indeed, severe COVID-19 can lead to multiple activation events, including inflammation, primary and secondary hemostasis, and fibrinolysis, all of which may contribute to cumulative D-dimer development. Finally, D-dimer testing has also found a role in the diagnosis and triaging of the so-called (COVID-19) vaccine-induced thrombotic thrombocytopenia.
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Affiliation(s)
- Jecko Thachil
- Department of Haematology, Manchester University Hospitals, Manchester, United Kingdom
| | - Emmanuel J Favaloro
- Department of Haematology, Institute of Clinical Pathology and Medical Research (ICPMR), NSW Health Pathology, Westmead Hospital, Westmead, New South Wales, Australia.,Sydney Centres for Thrombosis and Haemostasis, Westmead, New South Wales, Australia.,Faculty of Science and Health, Charles Sturt University, Wagga Wagga, New South Wales, Australia
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University Hospital of Verona, Verona, Italy
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24
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Sánchez FG, Fernández MM, Moreno JMBAYJS. [Diagnostic and treatment protocol for vascular complications of COVID-19]. Medicine (Baltimore) 2022; 13:3250-3255. [PMID: 35582696 PMCID: PMC9097964 DOI: 10.1016/j.med.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2023] Open
Abstract
The clinical spectrum of the disease caused by SARS-CoV-2 (COVID-19) is highly variable. It commonly has a mild or asymptomatic course. Around 15% to 20% of patients have lung involvement, which can progress to acute respiratory distress syndrome (ARDS) and multiple organ dysfunction syndrome, with marked alteration of the inflammatory and immune response. In these severe forms, there is an increased prevalence of vascular thrombotic complications which manifest as venous thromboembolism, acute arterial ischemia in the limbs, and, less frequently, myocardial involvement or cerebrovascular accident. The proposed pathogenic mechanisms include diffuse endothelial damage or endotheliitis, microvascular inflammation, cytokine release, hypercoagulability, and hypoxia. Early recognition of these complications is vital for improving the prognosis and survival of these patients.
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Affiliation(s)
- F García Sánchez
- Servicio de Medicina Interna. Hospital Universitario Príncipe de Asturias. Universidad de Alcalá. Alcalá de Henares. Madrid. España
| | - M Martín Fernández
- Servicio de Medicina Interna. Hospital Universitario Príncipe de Asturias. Universidad de Alcalá. Alcalá de Henares. Madrid. España
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25
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Affiliation(s)
- David W Louis
- Lifespan Cardiovascular Institute, 593 Eddy Street, RIH APC 730, Providence, RI 02903, USA; Department of Medicine, Division of Cardiology, Alpert Medical School of Brown University, 222 Richmond Street, Providence, RI 02903, USA
| | - Marwan Saad
- Lifespan Cardiovascular Institute, 593 Eddy Street, RIH APC 730, Providence, RI 02903, USA; Department of Medicine, Division of Cardiology, Alpert Medical School of Brown University, 222 Richmond Street, Providence, RI 02903, USA
| | - Shilpa Vijayakumar
- Lifespan Cardiovascular Institute, 593 Eddy Street, RIH APC 730, Providence, RI 02903, USA; Department of Medicine, Division of Cardiology, Alpert Medical School of Brown University, 222 Richmond Street, Providence, RI 02903, USA
| | - Suleman Ilyas
- Department of Medicine, Division of Cardiology, Alpert Medical School of Brown University, 222 Richmond Street, Providence, RI 02903, USA
| | - Aravind Kokkirala
- United States Department of Veterans Affairs Providence VA Medical Center, 830 Chalkstone Avenue, Providence, RI 02908, USA
| | - Herbert D Aronow
- Lifespan Cardiovascular Institute, 593 Eddy Street, RIH APC 730, Providence, RI 02903, USA; Department of Medicine, Division of Cardiology, Alpert Medical School of Brown University, 222 Richmond Street, Providence, RI 02903, USA.
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26
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The Composition and Physical Properties of Clots in COVID-19 Pathology. Diagnostics (Basel) 2022; 12:diagnostics12030580. [PMID: 35328132 PMCID: PMC8947364 DOI: 10.3390/diagnostics12030580] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 02/18/2022] [Accepted: 02/21/2022] [Indexed: 01/01/2023] Open
Abstract
Hemostasis is a finely tuned process of which dysregulation can lead either to bleeding or thrombotic complications. The latter is often caused by the hypercoagulable state as it is also seen in patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, i.e., in COVID-19 patients. COVID-19 patients requiring hospitalization often suffer from thrombotic events that could not be predicted using routine coagulation assays. Recently, several studies have reported ROtational ThromboElastoMetry (ROTEM) as a promising tool to predict outcomes in COVID-19 patients. In this review we give an overview of ROTEM with a particular focus on the interpretation of the symmetrical clot formation curve in relation to coagulopathy in COVID-19 patients. Furthermore, we have introduced new parameters that might help to better distinguish between COVID-19 patients and outcomes.
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27
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Teimury A, Khameneh MT, Khaledi EM. Major coagulation disorders and parameters in COVID-19 patients. Eur J Med Res 2022; 27:25. [PMID: 35168674 PMCID: PMC8845229 DOI: 10.1186/s40001-022-00655-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Accepted: 02/08/2022] [Indexed: 02/08/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19), with a high prevalence rate, has rapidly infected millions of people around the world. Since viral infections can disrupt the coagulation and homeostasis cascades, various inflammatory and coagulation problems occur due to COVID-19 infection, similar to coronavirus epidemics in 2003 and 2004. According to multiple previous studies, in the present research, we reviewed the most commonly reported problems of COVID-19 patients, such as venous thromboembolism, pulmonary embolism, disseminated intravascular coagulation, etc. and investigated the causes in these patients. Coagulation and inflammatory markers, such as platelets and fibrinogen, C-reactive protein, lactate dehydrogenase, d-dimer, prothrombin time, etc., were also discussed, and the treatment options were briefly reviewed. In addition to coagulation treatments, regular examination of coagulation parameters and thrombotic complications can be helpful in the timely treatment of patients. Therefore, it is helpful to review the coagulation problems in COVID-19 patients. Although all mentioned problems and markers are important in COVID-19, some of them are more valuable in terms of diagnosis and prognosis.
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Affiliation(s)
- Azadeh Teimury
- Department of Cell and Molecular Biology, University of Kashan, Kashan, Iran
| | - Mahshid Taheri Khameneh
- Center of Excellence for Biodiversity, Faculty of Natural Sciences, University of Tabriz, Tabriz, Iran
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28
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Petrov A, De Glee Romera JP, Wilbring M, Alexiou K, Kappert U, Matschke KE, Tugtekin SM. Aortic Thrombosis following COVID-19: A Systematic Review. Thorac Cardiovasc Surg 2022; 70:323-332. [PMID: 35108736 DOI: 10.1055/s-0041-1740554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Asen Petrov
- Department of Cardiac Surgery, University Heart Center Dresden, Dresden, Germany
| | | | - Manuel Wilbring
- Department of Cardiac Surgery, University Heart Center Dresden, Dresden, Germany
| | - Konstantin Alexiou
- Department of Cardiac Surgery, University Heart Center Dresden, Dresden, Germany
| | - Utz Kappert
- Department of Cardiac Surgery, University Heart Center Dresden, Dresden, Germany
| | | | - Sems-Malte Tugtekin
- Department of Cardiac Surgery, University Heart Center Dresden, Dresden, Germany
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29
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Xiao D, Tang F, Chen L, Gao H, Li X. Cumulative Evidence for the Association of Thrombosis and the Prognosis of COVID-19: Systematic Review and Meta-Analysis. Front Cardiovasc Med 2022; 8:819318. [PMID: 35146009 PMCID: PMC8821518 DOI: 10.3389/fcvm.2021.819318] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2021] [Accepted: 12/22/2021] [Indexed: 01/14/2023] Open
Abstract
Background Although thrombosis events have been reported in patients with coronavirus disease 2019 (COVID-19), the association between thrombosis and COVID-19-related critical status or risk of mortality in COVID-19 has been inconsistent. Objective We conducted a meta-analysis of reports assessing the association between thrombosis and the prognosis of COVID-19. Methods The EMBASE, Ovid-MEDLINE, and Web of Science databases were searched up to December 9, 2021, and additional studies were retrieved via manual searching. Studies were included if they reported the risk of COVID-19-related critical status or COVID-19-related mortality in relation to thrombosis. The related data were extracted by two authors independently, and a random effects model was conducted to pool the odds ratios (ORs). In addition, stratified analyses were conducted to evaluate the association. Results Among 6,686 initially identified studies, we included 25 studies published in 2020 and 2021, with a total of 332,915 patients according to predefined inclusion criteria. The associations between thrombosis and COVID-19-related mortality and COVID-19-related critical status were significant, with ORs of 2.61 (95% CI, 1.91–3.55, p < 0.05) and 2.9 (95% CI, 1.6–5.24, p < 0.05), respectively. The results were statistically significant and consistent in stratified analyses. Conclusions Thrombosis is associated with an increased risk of mortality and critical status induced by COVID-19. Further prospective studies with large sample sizes are required to establish whether these associations are causal by considering more confounders and to clarify their mechanisms. Observational studies cannot prove causality. However, autopsy studies show thrombosis events preceding COVID-19-related deaths. The results of this meta-analysis reported that thrombosis was associated with a 161% increased risk of mortality from COVID-19 and a 190% increased risk of COVID-19-related critical status. The type of thrombosis included in the original studies also seemed to be related to the results.
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Affiliation(s)
- Dongqiong Xiao
- Department of Emergency, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Fajuan Tang
- Department of Emergency, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
- *Correspondence: Fajuan Tang
| | - Lin Chen
- Department of Emergency, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Hu Gao
- Department of Emergency, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
| | - Xihong Li
- Department of Emergency, West China Second University Hospital, Sichuan University, Chengdu, China
- Key Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University), Ministry of Education, Chengdu, China
- Xihong Li
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30
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Jongkind V, Earnshaw JJ, Bastos Gonçalves F, Cochennec F, Debus ES, Hinchliffe R, Menyhei G, Svetlikov AV, Tshomba Y, Van Den Berg JC, Björck M. Editor's Choice - Update of the European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia in Light of the COVID-19 Pandemic, Based on a Scoping Review of the Literature. Eur J Vasc Endovasc Surg 2022; 63:80-89. [PMID: 34686452 PMCID: PMC8418912 DOI: 10.1016/j.ejvs.2021.08.028] [Citation(s) in RCA: 43] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 08/18/2021] [Accepted: 08/26/2021] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To perform a scoping review of how patients with COVID-19 are affected by acute limb ischaemia (ALI) and evaluate the recommendations of the 2020 ESVS ALI Guidelines for these patients. METHODS Research questions were defined, and a systematic literature search was performed following the PRISMA guidelines. Abstracts and unpublished literature were not included. The definition of ALI in this review is in accordance with the ESVS guidelines. RESULTS Most identified papers were case reports or case series, although population based data and data from randomised controlled trials were also identified. In total, 114 unique and relevant papers were retrieved. Data were conflicting concerning whether the incidence of ALI increased, or remained unchanged, during the pandemic. Case reports and series reported ALI in patients who were younger and healthier than usual, with a greater proportion affecting the upper limb. Whether or not this is coincidental remains uncertain. The proportion of men/women affected seems unchanged. Most reported cases were in hospitalised patients with severe COVID-19. Patients with ALI as their first manifestation of COVID-19 were reported. Patients with ALI have a worse outcome if they have a simultaneous COVID-19 infection. High levels of D-dimer may predict the occurrence of arterial thromboembolic events in patients with COVID-19. Heparin resistance was observed. Anticoagulation should be given to hospitalised COVID-19 patients in prophylactic dosage. Most of the treatment recommendations from the ESVS Guidelines remained relevant, but the following were modified regarding patients with COVID-19 and ALI: 1) CTA imaging before revascularisation should include the entire aorta and iliac arteries; 2) there should be a high index of suspicion, early testing for COVID-19 infection and protective measures are advised; and 3) there should be preferential use of local or locoregional anaesthesia during revascularisation. CONCLUSION Although the epidemiology of ALI has changed during the pandemic, the recommendations of the ESVS ALI Guidelines remain valid. The above mentioned minor modifications should be considered in patients with COVID-19 and ALI.
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Affiliation(s)
- Vincent Jongkind
- Department of Vascular Surgery, Amsterdam University Medical Centres, Amsterdam, the Netherlands.
| | | | - Frederico Bastos Gonçalves
- NOVA Medical School, Universidade NOVA de Lisboa & Centro Hospitalar Universitário de Lisboa Central, Portugal
| | | | - E. Sebastian Debus
- Department for Vascular Medicine (Vascular Surgery, Angiology, Endovascular Therapy), University Heart & Vascular Centre, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Robert Hinchliffe
- Bristol Centre for Surgical Research, Bristol NIHR Biomedical Research Centre, Bristol, UK
| | - Gabor Menyhei
- Department of Vascular Surgery, University of Pecs, Pecs, Hungary
| | - Alexei V. Svetlikov
- Division of Cardio-Vascular of the North-Western Medical University named after II Mechnikov, St Petersburg, Russia
| | - Yamume Tshomba
- Unit of Vascular Surgery, Fondazione Policlinico Universitario Gemelli IRCCS, Roma - Università Cattolica del Sacro Cuore, Rome, Italy
| | - Jos C. Van Den Berg
- Service of Interventional Radiology Centro Vascolare Ticino Ospedale Regionale di Lugano and Universitätsinstitut für Diagnostische, Interventionelle und Pädiatrische Radiologie Inselspital, Bern, Switzerland
| | - Martin Björck
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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31
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Acute Lower Limb Ischemia in COVID-19 Patient with Delayed Presentation. Case Rep Cardiol 2021; 2021:3333057. [PMID: 34925921 PMCID: PMC8674068 DOI: 10.1155/2021/3333057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Revised: 10/30/2021] [Accepted: 11/10/2021] [Indexed: 12/12/2022] Open
Abstract
Thromboembolism is a common complication of SARS-CoV-2, which generally involves venous thromboembolism, although there have been reported cases of arterial thrombosis affecting cerebral, coronary, and visceral arteries, as well as arteries in the extremities. We discuss a case of a 45-year-old diabetic man with COVID-19 who developed late-onset acute lower limb ischemia.
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32
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Ouyang J, Bajracharya S, John S, Wagner J, Xu J, Luo Y, Thaxton M, Salifu M, Yap E, Mallappallil M. Clotting of Hemodialysis Access in Patients with COVID-19 in an Inner-City Hospital. Nephron Clin Pract 2021; 146:179-184. [PMID: 34929702 PMCID: PMC8805045 DOI: 10.1159/000520174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 10/10/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND An increased incidence of thrombotic complications in patients with coronavirus disease 2019 (COVID-19) has been reported. Severe acute kidney injury (AKI) is one of the major clinical manifestations of COVID-19 with the need for renal replacement therapy. It was observed that hemodialysis (HD) accesses tended to thrombose more often in the COVID-19 population than in non-COVID-19 patients. We hypothesize that the hypercoagulable state of COVID-19 is associated with higher incidence of access clotting. METHOD In this retrospective single-centered study at Kings County Hospital in New York City, 1,075 patients with COVID-19 were screened, and 174 patients who received HD from January 3, 2021 to May 15, 2020 were enrolled to examine the risk factors of dialysis access clotting in patients with COVID-19. RESULTS Of the 174 patients, 109 (63%) were COVID-19 positive. 39 (22.6%) patients had dialysis access clotting at least once during their hospitalization, and they had significantly higher body mass index (BMI) (p = 0.001), higher rates of COVID-19 (p = 0.015), AKI (p < 0.001), higher platelet counts (p = 0.029), higher lactate dehydrogenase levels (p = 0.009), and lower albumin levels (p = 0.001) than those without access malfunctions. Low albumin levels (p = 0.008), AKI (p = 0.008), and high BMI (p = 0.018) were risk factors associated with HD access clotting among COVID-19 patients. CONCLUSION Patients with COVID-19 who receive HD for AKI with high BMI are at a higher risk of clotting their HD access.
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Affiliation(s)
- Jie Ouyang
- NYC Health + Hospitals, Kings County Hospital Center, Brooklyn, New York, USA, .,Downstate Medical Center- State University of Brooklyn, Brooklyn, New York, USA,
| | - Siddhartha Bajracharya
- NYC Health + Hospitals, Kings County Hospital Center, Brooklyn, New York, USA.,Downstate Medical Center- State University of Brooklyn, Brooklyn, New York, USA
| | - Sabu John
- NYC Health + Hospitals, Kings County Hospital Center, Brooklyn, New York, USA.,Downstate Medical Center- State University of Brooklyn, Brooklyn, New York, USA
| | - John Wagner
- NYC Health + Hospitals, Kings County Hospital Center, Brooklyn, New York, USA
| | - Jiehui Xu
- Division of Biostatistics, New York University, New York, New York, USA
| | - Yiming Luo
- Rheumatology, National Institute of Arthritis and Musculoskeletal and Skin Disease, Bethesda, Maryland, USA
| | - Mariah Thaxton
- NYC Health + Hospitals, Kings County Hospital Center, Brooklyn, New York, USA
| | - Moro Salifu
- NYC Health + Hospitals, Kings County Hospital Center, Brooklyn, New York, USA.,Downstate Medical Center- State University of Brooklyn, Brooklyn, New York, USA
| | - Ernie Yap
- NYC Health + Hospitals, Kings County Hospital Center, Brooklyn, New York, USA.,Downstate Medical Center- State University of Brooklyn, Brooklyn, New York, USA
| | - Mary Mallappallil
- NYC Health + Hospitals, Kings County Hospital Center, Brooklyn, New York, USA.,Downstate Medical Center- State University of Brooklyn, Brooklyn, New York, USA
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33
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Prasad M, Leon M, Lerman LO, Lerman A. Viral Endothelial Dysfunction: A Unifying Mechanism for COVID-19. Mayo Clin Proc 2021; 96:3099-3108. [PMID: 34863398 PMCID: PMC8373818 DOI: 10.1016/j.mayocp.2021.06.027] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 05/12/2021] [Accepted: 06/09/2021] [Indexed: 01/08/2023]
Abstract
The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a highly transmissible virus with significant global impact, morbidity, and mortality. The SARS-CoV-2 virus may result in widespread organ manifestations including acute respiratory distress syndrome, acute renal failure, thromboembolism, and myocarditis. Virus-induced endothelial injury may cause endothelial activation, increased permeability, inflammation, and immune response and cytokine storm. Endothelial dysfunction is a systemic disorder that is a precursor of atherosclerotic vascular disease that is associated with cardiovascular risk factors and is highly prevalent in patients with atherosclerotic cardiovascular and peripheral disease. Several studies have associated various viral infections including SARS-CoV-2 infection with inflammation, endothelial dysfunction, and subsequent innate immune response and cytokine storm. Noninvasive monitoring of endothelial function and identification of high-risk patients who may require specific therapies may have the potential to improve morbidity and mortality associated with subsequent inflammation, cytokine storm, and multiorgan involvement.
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Affiliation(s)
- Megha Prasad
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, Columbia University, New York City, NY; Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
| | - Martin Leon
- Division of Cardiology, Department of Medicine, Columbia University Medical Center, Columbia University, New York City, NY
| | - Lilach O Lerman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN; Division of Nephrology and Hypertension, Mayo Clinic, Rochester, MN
| | - Amir Lerman
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN.
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34
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Narasimhan B, Lorente-Ros M, Aguilar-Gallardo JS, Lizardo CP, Narasimhan H, Morton C, Donahue KR, Aronow WS. Anticoagulation in COVID-19: a review of current literature and guidelines. Hosp Pract (1995) 2021; 49:307-324. [PMID: 34807786 DOI: 10.1080/21548331.2021.2007648] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Severe acute respiratory syndrome coronavirus 2 infections are associated with greater risk of both arterial and venous thromboembolic events.Pathophysiology and Clinical implications: This has been attributed to a florid proinflammatory state resulting in microvascular dysfunction, activation of platelets and procoagulant systems as well as possible direct endothelial injury. The associated morbidity and mortality of these events has prompted much speculation and varied anticoagulation and fibrinolytic strategies based on multiple criteria including disease severity and biomarkers. No clear definitive benefit has been established with these approaches, which have frequently led to greater bleeding complications without significant mortality benefit.Overview: In this review, we outline the burden of these thromboembolic events in coronavirus disease-2019 (COVID-19) as well as the hypothesized contributory biological mechanisms. Finally, we provide a brief overview of the major clinical studies on the topic, and end with a summary of major societal guideline recommendations on anticoagulation in COVID-19.
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Affiliation(s)
- Bharat Narasimhan
- Debakey Cardiovascular Center, Houston Methodist Hospital-Texas Medical Center, Houston, TX, USA
| | - Marta Lorente-Ros
- Department of Medicine, Mount Sinai Morningside-West, the Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jose S Aguilar-Gallardo
- Department of Medicine, Mount Sinai Morningside-West, the Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Christopher Perez Lizardo
- Department of Medicine, Mount Sinai Morningside-West, the Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Celia Morton
- Department of Pharmacy, Houston Methodist Hospital-Texas Medical Center, Houston, TX, USA
| | - Kevin R Donahue
- Department of Pharmacy, Houston Methodist Hospital-Texas Medical Center, Houston, TX, USA
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center/New York Medical College, Valhalla, NY, USA
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35
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Jenner WJ, Gorog DA. Incidence of thrombotic complications in COVID-19 : On behalf of ICODE: The International COVID-19 Thrombosis Biomarkers Colloquium. J Thromb Thrombolysis 2021; 52:999-1006. [PMID: 34047938 PMCID: PMC8161345 DOI: 10.1007/s11239-021-02475-7] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/03/2021] [Indexed: 12/13/2022]
Abstract
A high incidence of thrombosis in hospitalised patients with COVID-19 was identified early during the pandemic. Accurately quantifying thrombotic risk may assist prognosis and guide appropriate thromboprophylaxis. Observational studies have estimated the rate of thrombosis in both hospitalised and non-hospitalised patients with COVID-19, and how this corresponds to the severity of illness. In this review, we provide an overview of the incidence and prevalence of arterial and venous thrombotic events in patients with COVID-19 and highlight the limitations in the studies to date. Asymptomatic individuals with COVID-19 and those with mild symptoms are at very low risk of thrombotic complications. However, rates of thrombosis are substantially increased in hospitalised patients, and are strikingly high in those patients who are critically-ill requiring treatment on the intensive care unit and especially those requiring extracorporeal membrane oxygenation. Clinicians managing such patients need to be aware of these risks and take appropriate steps with respect to thromboprophylaxis and heightened clinical vigilance. Large prospective observational studies will more accurately quantify thrombotic rate, and randomized controlled trials are currently investigating optimal thromboprophylactic strategies.
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Affiliation(s)
- William J Jenner
- Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, UK
| | - Diana A Gorog
- Cardiology Department, East and North Hertfordshire NHS Trust, Stevenage, Hertfordshire, UK.
- Faculty of Medicine, Imperial College, National Heart and Lung Institute, London, UK.
- School of Life and Medical Sciences, Postgraduate Medical School, University of Hertfordshire, Hatfield, UK.
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Massaro G, Lecis D, Martuscelli E, Chiricolo G, Sangiorgi GM. Clinical Features and Management of COVID-19–Associated Hypercoagulability. Card Electrophysiol Clin 2021; 14:41-52. [PMID: 35221084 PMCID: PMC8556574 DOI: 10.1016/j.ccep.2021.10.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Antunes de Brito CA, de Oliveira Filho JRB, Marques DT, Lencastre MDC, de Almeida JR, Lopes EP. COVID-19 and Hepatic Artery Thrombosis: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2021; 22:e932531. [PMID: 34333508 PMCID: PMC8340922 DOI: 10.12659/ajcr.932531] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Patient: Female, 45-year-old Final Diagnosis: COVID-19 • hepatic artery thrombosis Symptoms: Abdominal pain • anosmia • asthenia • cough • dysgeusia • headache • myalgia • sore throat Medication: — Clinical Procedure: Anticoagulant Specialty: Gastroenterology and Hepatology • Infectious Diseases
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Affiliation(s)
- Carlos Alexandre Antunes de Brito
- Department of Internal Medicine, Center of Medical Sciences of Federal University of Pernambuco, Recife, PE, Brazil.,Department of Immunology, Autoimmune Research Institute, Recife, PE, Brazil
| | | | - Diogo Torres Marques
- Department of Radiology, Royal Portuguese Hospital of Beneficence, Recife, PE, Brazil
| | - Maria do Carmo Lencastre
- Alberto Ferreira da Costa Institute, Royal Portuguese Hospital of Beneficence, Recife, PE, Brazil
| | - José Roberto de Almeida
- Department of Internal Medicine, Center of Medical Sciences of Federal University of Pernambuco, Recife, PE, Brazil
| | - Edmundo Pessoa Lopes
- Department of Internal Medicine, Center of Medical Sciences of Federal University of Pernambuco, Recife, PE, Brazil
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Aljamaan FS. Unusual Presentation of a Severe COVID-19 Case With Axillary Artery Thrombosis. Cureus 2021; 13:e15036. [PMID: 34150387 PMCID: PMC8200903 DOI: 10.7759/cureus.15036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2021] [Indexed: 11/30/2022] Open
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has been evolving since early 2020 with high critical care mortality and morbidity. High mortality rates have been linked largely to respiratory failure. Hypercoagulability status induced by the massive inflammatory storm has led to a high rate of thrombotic events, whether arterial or venous, contributing to COVID-19 mortality especially in critically ill patients. Thrombotic events might be the presenting feature of the disease or might happen during hospitalization. In this case report, we describe a case of a 67-year-old male with severe COVID-19 pneumonia who was found on presentation to have left axillary artery thrombosis requiring embolectomy; the case was managed successfully. We reviewed the pathophysiology of hypercoagulability associated with COVID-19, clinical implications, and most recent treatment recommendations.
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Tacquard C, Mansour A, Godon A, Gruel Y, Susen S, Godier A, Albaladejo P. Anticoagulation in COVID-19: not strong for too long? Anaesth Crit Care Pain Med 2021; 40:100857. [PMID: 33798761 PMCID: PMC8008784 DOI: 10.1016/j.accpm.2021.100857] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Charles Tacquard
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, 1, Place de l'Hôpital, 67091 Strasbourg Cedex, France.
| | - Alexandre Mansour
- Department of Anaesthesiology Critical Care Medicine and Perioperative Medicine, CHU de Rennes, Rennes, France
| | - Alexandre Godon
- Department of Anaesthesiology and Critical Care, Grenoble Alpes University Hospital, Grenoble, France
| | - Yves Gruel
- Department of Haematology-Haemostasis, Tours University Hospital, France
| | - Sophie Susen
- Heart and Lung Institute, Haemostasis Department, CHU Lille, 59037 Lille Cedex, France
| | - Anne Godier
- Department of Anaesthesiology and Critical Care, European Georges Pompidou Hospital, Assistance Publique-Hôpitaux de Paris, Paris University, Paris, France
| | - Pierre Albaladejo
- Department of Anaesthesiology and Critical Care, Grenoble Alpes University Hospital, Grenoble, France
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40
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Tu TM, Seet CYH, Koh JS, Tham CH, Chiew HJ, De Leon JA, Chua CYK, Hui ACF, Tan SSY, Vasoo SS, Tan BYQ, Umapathi NT, Tambyah PA, Yeo LLL. Acute Ischemic Stroke During the Convalescent Phase of Asymptomatic COVID-2019 Infection in Men. JAMA Netw Open 2021; 4:e217498. [PMID: 33885771 PMCID: PMC8063067 DOI: 10.1001/jamanetworkopen.2021.7498] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
IMPORTANCE Acute ischemic stroke (AIS) is a known neurological complication in patients with respiratory symptoms of COVID-19 infection. However, AIS has not been described as a late sequelae in patients without respiratory symptoms of COVID-19. OBJECTIVE To assess AIS experienced by adults 50 years or younger in the convalescent phase of asymptomatic COVID-19 infection. DESIGN, SETTING, AND PARTICIPANTS This case series prospectively identified consecutive male patients who received care for AIS from public health hospitals in Singapore between May 21, 2020, and October 14, 2020. All of these patients had laboratory-confirmed asymptomatic COVID-19 infection based on a positive SARS-CoV-2 serological (antibodies) test result. These patients were individuals from South Asian countries (India and Bangladesh) who were working in Singapore and living in dormitories. The total number of COVID-19 cases (54 485) in the worker dormitory population was the population at risk. Patients with ongoing respiratory symptoms or positive SARS-CoV-2 serological test results confirmed through reverse transcriptase-polymerase chain reaction nasopharyngeal swabs were excluded. MAIN OUTCOMES AND MEASURES Clinical course, imaging, and laboratory findings were retrieved from the electronic medical records of each participating hospital. The incidence rate of AIS in the case series was compared with that of a historical age-, sex-, and ethnicity-matched national cohort. RESULTS A total of 18 male patients, with a median (range) age of 41 (35-50) years and South Asian ethnicity, were included. The median (range) time from a positive serological test result to AIS was 54.5 (0-130) days. The median (range) National Institutes of Health Stroke Scale score was 5 (1-25). Ten patients (56%) presented with a large vessel occlusion, of whom 6 patients underwent intravenous thrombolysis and/or endovascular therapy. Only 3 patients (17%) had a possible cardiac source of embolus. The estimated annual incidence rate of AIS was 82.6 cases per 100 000 people in this study compared with 38.2 cases per 100 000 people in the historical age-, sex-, and ethnicity-matched cohort (rate ratio, 2.16; 95% CI, 1.36-3.48; P < .001). CONCLUSIONS AND RELEVANCE This case series suggests that the risk for AIS is higher in adults 50 years or younger during the convalescent period of a COVID-19 infection without respiratory symptoms. Acute ischemic stroke could be part of the next wave of complications of COVID-19, and stroke units should be on alert and use serological testing, especially in younger patients or in the absence of traditional risk factors.
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Affiliation(s)
- Tian Ming Tu
- Department of Neurology, National Neuroscience Institute, Singapore
| | | | | | | | - Hui Jin Chiew
- Department of Neurology, National Neuroscience Institute, Singapore
| | | | | | - Andrew Che-Fai Hui
- Division of Neurology, Department of Medicine, Ng Teng Fong General Hospital, Singapore
| | - Shaun Shi Yan Tan
- Department of Laboratory Medicine, National University Health System, Singapore
| | - Shawn Sushilan Vasoo
- Department of Infectious Diseases, Tan Tock Seng Hospital and National Centre for Infectious Diseases, Singapore
| | | | | | - Paul Anantharajah Tambyah
- Division of Infectious Diseases, Department of Medicine, National University Health System, Singapore
| | - Leonard Leong Litt Yeo
- Division of Neurology, Department of Medicine, National University Health System, Singapore
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Affiliation(s)
- Robert D McBane
- Vascular Division, Department of Cardiology, Gonda Vascular Center, Mayo Clinic, Rochester, MN.
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