key: cord-0793317-x0d3qlj2
authors: Etkin, Yana; Conway, Allan M.; Silpe, Jeffrey; Qato, Khalil; Carroccio, Alfio; Manvar-Singh, Pallavi; Giangola, Gary; Deitch, Jonathan S.; Davila-Santini, Luis; Schor, Jonathan A.; Singh, Kuldeep; Mussa, Firas F.; Landis, Gregg S.
title: Acute arterial thromboembolism in patients with COVID-19 in the New York City area
date: 2020-08-28
journal: Ann Vasc Surg
DOI: 10.1016/j.avsg.2020.08.085
sha: 0ca99be5935af5720a1a897b49002b6c9fb1ab85
doc_id: 793317
cord_uid: x0d3qlj2

BACKGROUND: Coronavirus disease 2019 (COVID-19) predisposes to arterial and venous thromboembolic complications. We describe the clinical presentation, management, and outcomes of acute arterial ischemia and concomitant infection at the epicenter of cases in the United States. METHODS: Patients with confirmed COVID-19 infection between March 1, 2020 and May 15, 2020 with an acute arterial thromboembolic event were reviewed. Data collected included demographics, anatomical location of the thromboembolism, treatments, and outcomes. RESULTS: Over the 11-week period, Northwell Health System cared for 12,630 hospitalized patients with COVID-19. A total of 49 patients with arterial thromboembolism and confirmed COVID-19 were identified. Median age was 67 years (58-75) and 37 (76%) were male. The most common preexisting conditions were hypertension (53%) and diabetes (35%). Median D-dimer level was 2673 ng/mL (723-7139). The distribution of thromboembolic events included upper 7 (14%) and lower 35 (71%) extremity ischemia, bowel ischemia 2 (4%), and cerebral ischemia 5 (10%). Six patients (12%) had thrombus in multiple locations. Concomitant deep vein thrombosis was found in 8 patients (16%). Twenty-two (45%) patients presented with signs of acute arterial ischemia and were subsequently diagnosed with COVID-19. The remaining 27 (55%) developed ischemia during hospitalization. Revascularization was performed in 13 (27%) patients, primary amputation in 5 (10%), administration of systemic tissue plasminogen activator in 3 (6%), and 28 (57%) were treated with systemic anticoagulation only. The rate of limb loss was 18%. Twenty-one patients (46%) died in the hospital. Twenty-five (51%) were successfully discharged and 3 patients are still in the hospital. CONCLUSIONS: While the mechanism of thromboembolic events in patients with COVID-19 remains unclear, the occurrence of such complication is associated with acute arterial ischemia which results in a high limb loss and mortality.

From the world's largest experience with COVID-19, we report the clinical presentation, While the mechanism of thromboembolic events in patients with COVID-19 remains unclear, the 102 occurrence of such complication is associated with acute arterial ischemia which results in a 103 high limb loss and mortality.

In December 2019, a series of pneumonia cases of unknown origin were identified in Wuhan,

China. 1 The pathogen has since been identified as a novel enveloped RNA betacoronavirus that 110 has been named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). 2 

The purpose of this study was to review the incidence, clinical presentation, management and 124 outcomes with 46 consecutive cases with acute arterial thrombosis in patients with confirmed and were intubated prior to onset of ischemia. The median D-dimer level was 2673 (IQR=723-163 7139) and 83% of patients had D-dimer above 1,000ng/ml. Twenty-two (45%) patients 164 presented with signs of acute arterial ischemia and were subsequently diagnosed with COVID- 

The rate of limb loss was 18% and overall, in-hospital mortality was 46%. Mortality in patients 183 with lower limb ischemia was 50% and in patients with mesenteric ischemia it was 100%. Forearm (ulnar, radial) 3/7 (43) SMA thrombosis with bowel ischemia 2 (4) Renal artery thrombosis 5 (10) Splenic artery thrombosis 3 (6) CVA with carotid artery thrombosis 5 (10) Asymptomatic with thoracic aortic thrombus 1 (2) Thrombosis in multiple locations † 6 (12) *Percentages may not total 100 because of rounding. † concomitant thrombus in the SMA, renal arteries, lower and upper extremity arteries. SMA denotes superior mesenteric artery and CVA cerebrovascular accident.

Clinical features of patients infected with 2019 novel 16

Mesenteric revascularization: 315 management and outcomes in the United States

Revascularization for acute mesenteric ischemia

Procoagulant activity during viral infections

Coagulation disorders in coronavirus infected patients: 321 COVID-19, SARS-CoV-1, MERS-CoV and lessons from the past

Hospital-associated outbreak of middle

J o u r n a l P r e -p r o o f Race and ethnic group were reported by the patient or were determined by family or physician if patient was non-communicative.