key: cord-0797742-q7yavza2
authors: Gomez-Arbelaez, Diego; Ibarra-Sanchez, Gabriela; Garcia-Gutierrez, Ania; Comanges-Yeboles, Alejandra; Ansuategui-Vicente, Marina; Gonzalez-Fajardo, Jose Antonio
title: COVID-19-RELATED AORTIC THROMBOSIS: A REPORT OF FOUR CASES
date: 2020-05-29
journal: Ann Vasc Surg
DOI: 10.1016/j.avsg.2020.05.031
sha: 8392a331c8e6f963e67b315b8eb0c8e6cd2ab2b6
doc_id: 797742
cord_uid: q7yavza2

COVID-19 may predispose patients to an increased risk of thrombotic complications through various pathophysiological mechanisms. Most of the reports on a high incidence of thrombotic complications are in relation to deep vein thrombosis and pulmonary embolism, while the evidence about arterial thrombosis in patients with COVID-19 is limited. We describe four cases of aortic thrombosis and associated ischemic complications in patients with severe SARS-CoV-2 infection.

Coronavirus disease 2019 (COVID-19) is a viral respiratory illness caused by the severe acute 39 respiratory syndrome coronavirus 2 (SARS-CoV-2), which was first described in Wuhan, China 40 and later declared by the World Health Organization as pandemic [1] 

Characteristics of the four patients (3 men and 1 woman) are summarized in Table 1 . The mean 51 age of patients was 65.5 years (range, 50-76 years) and their medical history was consistent for 52 hypertension (Case-1), and hypertension, dyslipidemia and psoriasis (Case-3), the other two 53 patients (Cases-2 and -4) were otherwise healthy. All the patients were admitted to our hospital 54 by respiratory symptoms compatible with COVID-19 (i.e., fever, cough and dyspnea) during all patients received empirical antibiotic and antiviral treatment, supportive therapies and 58 antithrombotic prophylaxis with low-molecular-weight heparins (LMWHs). 59

Despite the antithrombotic prophylaxis, the patients developed aortic thrombosis ( Figure 1 ) 60 and subsequent diverse ischemic events. The mean time from disease onset to thrombotic 61 event was 14.7 days (range, 12-17 days). Case-1 presented pain, coldness and paleness of 62 sudden onset in both legs suggesting acute limb ischemia (ALI), and the computed tomographic 63 angiography (CTA) confirmed an aortoiliac thrombosis. Case-2 also presented aortoiliac 64 ferritin (mean 3014 ng/mL, range 568-8203 ng/mL, and interleukin-6 (mean 619.5, range 176-79 1138 pg/mL) were significantly increased in all patients (Table 1) . 80 A bilateral retrograde transfemoral thrombectomy was performed in Cases-1 and -2 with acute 81 lower limb ischemia. Posteriorly, Case-1 presented episodes of re-thrombosis, requiring a major 82 limb amputation due to persistent critical ischemia and died 5 days later from acute mesenteric 83 ischemia and multi-organ failure. Case-2 evolved uneventful for the leg ischemia, but with 84 neurological deficit by the stroke. Case-3 evolved with neurological deficit and the thrombus 85 was washed with the heparin. Case-4 was also treated conservatively with full anticoagulation 86 and evolved uneventful. the evidence about arterial thrombosis in patients with COVID-19 is limited [7] . An acute 92 thrombosis of an aortic prosthetic graft in a patient with COVID-19 has been also described [8] . 93

We reported four cases of aortic thrombosis and associated ischemic complications in patients 94 with severe SARS-CoV-2 infection. 95

In our series, thrombotic events were more common in men than in women (3:1). The cases 96 described in the present paper were otherwise healthy patients, except for hypertension and 97 dyslipidemia in two cases, and had no history of known prothrombotic disease or atrial 98 fibrillation. All thrombotic events occurred despite the use of antithrombotic prophylaxis, and 6 even episodes of re-thrombosis occurred despite full anticoagulation (e.g., Case-1). Therefore, 100 it seems reasonable to attribute these thrombotic complications to a severe hypercoagulable 101 state associated with COVID-19. To note, all of our patients had a severe presentation of the 102 SARS-CoV-2 infection and required admission to the intensive care unit (ICU). The two case of 103 aortoiliac thrombosis and ALI underwent surgery, and given the limitations caused by infection, 104

we opted for the simplest option to restore blood flow (thrombectomy). The other two cases 105 with free-floating thrombus evolved satisfactorily with full anticoagulation. 

World Health Organization. Coronavirus disease (COVID-19) Pandemic

Patients With 2019 Novel Coronavirus-Infected Pneumonia in Wuhan, China. JAMA. 2020

Antithrombotic Therapy, 148 and Follow-up

Hypercoagulability in Patients Admitted to Intensive Care Unit for Acute Respiratory Failure

Abnormal coagulation parameters are associated with poor 154 prognosis in patients with novel coronavirus pneumonia

Incidence of 157 venous thromboembolism in hospitalized patients with COVID-19

Concomitant acute aortic thrombosis and 160 pulmonary embolism complicating COVID-19 pneumonia

Acute thrombosis of an 163 aortic prosthetic graft in a patient with severe COVID-19 related pneumonia

Anticoagulant treatment is associated with 166 decreased mortality in severe coronavirus disease 2019 patients with coagulopathy

Antibodies in Patients with Covid-19

*Anticardiolipin IgG and IgM, anti-b2-glycoprotein I IgA, IgG and IgM. EGFR: estimated glomerular filtration rate

AMI: acute mesenteric ischemia; DVT: deep vein thrombosis; PE: pulmonary embolism; ND: not determined

Antiphospholipid antibodies* ND Normal Normal ND

COVID-19 is associated with an increased thrombotic risk, and those events in the venous 122 system are the most frequent. Although aortic thrombosis is a rare event, its possible 123 appearance underscores the need to initiate complete anticoagulation in patients at risk (i.e., 124 ICU, high levels of D-dimer and interleukin-6) and to maintain it over time. According to our 125 experience, we suggest maintaining full anticoagulation for at least 1-2 months after hospital 126 discharge with LMWHs due to its anti-inflammatory effect and to facilitate the ambulatory 127 control. After normalization of the analytical parameters, particularly D-dimer, the long-term 128 treatment must be individualized. Nonetheless, further research is required to better 129