key: cord-0690191-z3cr9im0 authors: Muhammad, Kamel; Tantawy, Tamer Ghatwary; Makar, Ragai R.; Olojugba, Oladeji title: Successful Catheter-directed thrombolysis for acute lower limb ischemia secondary to COVID-19 infection date: 2020-11-03 journal: Ann Vasc Surg DOI: 10.1016/j.avsg.2020.09.044 sha: 4c245a79abe6af56b63d16e80d4a77ec8e8d9fd7 doc_id: 690191 cord_uid: z3cr9im0 A 49-year-old man was admitted to his local hospital with left leg pain and breathing difficulties. He had negative nasopharyngeal polymerase-chain-reaction tests for SARS-CoV-2. Chest X-ray and Computed-Tomography Pulmonary Angiogram displayed typical COVID-19 radiological features as ground-glass opacities and bronchovascular thickening. His respiratory symptoms resolved after four days of supportive treatment, while his left leg became more painful and discoloured. He was referred to our centre with acute left leg ischaemia. CT Angiogram revealed eccentric mural thrombus at the aortic bifurcation, extending into left common iliac and an abrupt occlusion of left popliteal, tibioperoneal and posterior tibial arteries. He was treated with Catheter-directed thrombolysis for 48-hours that achieved successful revascularisation of the ischaemic limb with no intervention-related complications. At six-weeks follow-up, he showed full recovery. Our case demonstrates that catheter-directed thrombolysis is a successful and safe treatment option in a COVID-19 patient with acute arterial occlusion. leg became more painful and discoloured. He was referred to our centre with acute left leg 23 ischaemia. CT Angiogram revealed eccentric mural thrombus at the aortic bifurcation, 24 extending into left common iliac and an abrupt occlusion of left popliteal, tibioperoneal and 25 posterior tibial arteries. He was treated with Catheter-directed thrombolysis for 48-hours 26 that achieved successful revascularisation of the ischaemic limb with no intervention-27 related complications. At six-weeks follow-up, he showed full recovery. Our case 28 demonstrates that catheter-directed thrombolysis is a successful and safe treatment option 29 in a COVID-19 patient with acute arterial occlusion. week history of irritating cough, fever, headache, malaise and myalgia. He was self- 48 isolating in his house with his family, as per the government guidance. Towards the end of 49 his period of self-isolation, he experienced worsening shortness of breath and left leg pain 50 that required hospital admission under the medical team at his local district general 51 hospital. He had Chest X-ray and Computed-Tomography Pulmonary Angiogram and was 52 tested twice for COVID-19 by nasal antigen swabs. His lungs showed radiological features 53 of ground-glass opacities and bronchovascular thickening that were highly suggestive of 54 COVID-19 infection; however, both swab tests were negative. The patient stayed in the 55 hospital for four days, during which he required nasal oxygen. His general condition and 56 most of his respiratory COVID-19 symptoms improved. However, his leg pain worsened, 57 and he had trouble walking. At this point, the left leg was found to be cold with no palpable 58 pulses below the groins, impaired sensation but normal power. An urgent CT Peripheral 59 Angiogram was performed. He was anticoagulated using Low Molecular Weight Heparin 60 (Tinzaparin 15,000 IU) and referred urgently to our regional vascular centre. On arrival to the vascular hub unit, the patient was normotensive with a blood pressure of 63 125/75 mm Hg, had a sinus-rhythm tachycardia with a heart rate of 125 bpm, oxygen 64 saturation of 95%, tachypnoea of 24 breaths/minute, and a temperature of 38.1 ºC, scoring 65 (4) on the National Early Warning Score chart, 4 . The vascular assessment of the lower limbs 66 showed a pale looking left foot, colder than the right side with prolonged capillary refill 67 time (> 4 seconds) and minimal calf tenderness. Neurologically, there was sensory 68 impairment affecting the toes with no associated limb weakness. There were palpable 69 bilateral femoral pulses with absent pulses on the left popliteal and pedal arteries. There The incidence of thromboembolic complications in patients with COVID-19 is as high as 35-187 45%, 10 . A recent study from Lombardy, Italy, showed a notable rise in the incidence of 188 acute threatening limb ischemia due to hypercoagulability linked to COVID-19 infection, 11 . 189 The pathophysiology of COVID-19 induced thrombosis is recently explained, 12 . Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China The species Severe acute respiratory syndrome-related 309 coronavirus: classifying 2019-nCoV and naming it SARS-CoV-2 Novel Coronavirus-Important Information for Clinicians National Early Warning Score (NEWS) 2: Standardising the assessment of 314 acute-illness severity in the NHS. 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