key: cord-0837416-5r1lhu04 authors: Borulu, Ferhat; Erkut, Bilgehan title: Severe Aortic Thrombosis in the early period after COVID-19: Two cases date: 2021-01-22 journal: Ann Vasc Surg DOI: 10.1016/j.avsg.2021.01.057 sha: 3b1e972c3b1d4328fb49a069e01107895e730a8b doc_id: 837416 cord_uid: 5r1lhu04 A total occlusion of the aorta is a rare condition; however, while rare, it has a very high mortality rate. Coronavirus disease 2019 (COVID-19) poses serious health problems, including vascular problems. Inflammatory changes produced by viral infections can cause serious disturbances in the coagulation system. Although cases showing a marked increase in thrombotic activity in the venous system have been presented, thrombosis in the arterial system, especially in the aorta, has rarely been reported. Here, we present two patients admitted to our hospital with an acute aortic thrombosis. Coronavirus disease 2019 (COVID-19), which first started in Wuhan, China at the end of 2019, became a pandemic in a short time. COVID-19 is a viral infection and is also defined as severe acute respiratory syndrome (SARS-CoV-2) (1) . It has been reported that the respiratory system is mainly affected by this severe disease, and coagulopathy has an important place in the high mortality rate (2). It has been demonstrated that pathophysiological mechanisms, such as inflammation, immobilization, and endothelial dysfunction, are involved in the occurrence of this condition (3) . Thrombus events (e.g., deep vein thrombus and pulmonary embolism), especially in the venous system, have been well defined since the onset of the disease (4, 5) . Arterial occlusions due to susceptibility to this coagulopathy are also expected. However, arterial occlusion events reflected in the literature have been limited compared to those reporting venous events. Thromboses, especially at the aortic level, have rarely been reported. In this report, we present two patients, one with a total aortic thrombosis and the other with a partial thrombosis of the descending aorta and a subsequent lower extremity arterial thrombosis. Permissions for these presentations were obtained from the patients and their relatives. COVID-19 diagnoses of both patients were confirmed by reverse transcriptase-polymerase chain reaction (PCR) examinations in the healthcare institutions they applied to before being admitted to our hospital. Moderate COVID-compatible changes were detected in the computed tomography (CT) examinations of both patients. In Table 1 , laboratory data and other demographic characteristics of both patients at the time of admission to our hospital are given. (2 x 40 mg), levofloxacin (1 x 500 mg/7 days), and enoxaparin (2 x 0.6 IU/ml). Anticoagulant treatment was not given once the patient was discharged. Six days after his discharge, he applied to the same center with complaints of abdominal and low back pain and cold legs. The patient, who was re-hospitalized, was sent to our hospital when it was observed that the aorta was thrombosed in the contrast-enhanced CT taken after cyanosis began in the legs in the following hours ( Figure 1 ). On admission to our hospital, there was significant cyanosis in both extremities. After the necessary preparations were made, he was urgently surgically treated. 4 Surgical procedure: A thrombectomy was performed with a Fogarty catheter from the common femoral arteries with incisions made under local anesthesia in both groin areas. Abundant thrombus material was taken from both femoral arteries. The operation was performed because of the strong antegrade flow and sufficient retrograde flow. A pulse was obtained in both lower extremities after the procedure. However, as metabolic acidosis became evident in the following hours, he died at the postoperative 18th hour. A 49-year-old male patient applied to another hospital with a fever and cough twenty days before his admission. The patient had a history of diabetes mellitus (20 years) and coronary artery disease (5 years) and was hospitalized with moderate pulmonary involvement after a thoracic CT. With a positive PCR test, the diagnosis of COVID-19 was confirmed. He was hospitalized for 13 days. He was then re-admitted to the hospital with sudden pain and a loss of heat in his right leg 7 days after discharge. Surgical intervention (embolectomy) was performed following the detection of a thrombus in both the descending aorta and the right main femoral artery (Figure 2 ). The same surgical intervention was performed again when there were signs of ischemia after the procedure (6 hours later). In the hours after this procedure, the patient, whose ischemia continued to increase at the level below the knee, was transferred to our hospital. The patient, who had signs of compartment syndrome on admission to our hospital, was surgically treated after the examinations. Surgical procedure: Revascularization (popliteal artery-tibialis posterior) and a fasciotomy were performed using the saphenous vein. He was amputated below the knee level due to both bleeding that was difficult to control and ischemia. He was discharged after wound care. Although serious thrombi in the aorta are extremely rare, they can have serious clinical consequences. An acute aortic obstruction (AAT) is a rare condition that occurs with a saddle embolism of the aorta or an atherosclerotic aortic thrombosis (6) . Although it is rarely seen, it 5 has a mortality rate reaching 75% (7, 8) . Because it is a rare condition, the information in the literature is generally in the form of case reports. COVID-19 creates a viral infection picture that can cause serious mortality risks, especially in patients with comorbid risk factors (9) . Clotting and related complications are a typical feature of this viral infection. Although this is more common in venous structures, it can also be seen in arterial structures. There have been few case reports concerning thromboses in medium-and large-sized arteries(10, 11, 12) . The inflammatory process triggered by this viral infection and the thrombotic process can accelerate after macrophage activation (13) . The absence of a vascular problem and a risk factor, such as atrial fibrillation, in our two patients suggested a viral infection as the cause of coagulopathy. Endothelial dysfunction can easily occur in these patients with the direct effect of the virus on the endothelial cells and the effect of cytokines and acute phase reactants (14) . The marked elevation in the laboratory values in both patients supports this idea. As in other patients presenting with a vascular thrombosis, D-dimer, fibrinogen, ferritin, and C-reactive protein (CRP) values were markedly elevated in our patients. Another reason for an increased susceptibility to hypercoagulopathy may be that these patients had not fully mobilized because they were still in the recovery process after the disease. Although some theories have been proposed, it is unclear how COVID-19 causes coagulopathy. While neither of our patients had a previously diagnosed hematological disease, the high hematocrit and hemoglobin values suggest that it may affect the formation of thromboses by increasing the viscosity of the blood. Although the etiopathogenesis is not fully clear, it is accepted that patients with COVID-19 have severe coagulation disorders. This shows us the importance of anticoagulant therapy in the active infection period and during the early discharge period when the inflammatory process continues. Studies have shown that heparin use significantly reduces mortality, especially in patients with high D-dimer levels (14) . The absence of anticoagulant therapy for 6 the period after discharge seems to have contributed significantly to the occurrence of these clinical complications. Thromboses, which resulted in limb loss and mortality, occurred over a very short period in both of our patients after the COVID-19 treatment was completed and the patients were discharged. There is a significant increase in the risk of thrombosis in both the arterial and venous systems in patients with COVID-19. Therefore, it is important to evaluate the appropriate prophylaxis and vascular structure (15). It would not be wrong to think that the inflammatory process triggered by the disease continues and this situation lays the groundwork for coagulopathy. The large amount of laboratory data in our two patients, which are considered as poor prognosis criteria in the process of viral infection treatments, indicates the importance of continuing anticoagulant treatment, especially in these patients after discharge. COVID-19 creates a pronounced tendency for thrombosis, especially in the venous system. Although a thrombosis at the aortic level is rare, it would be appropriate to continue anticoagulant therapy after discharge, especially in patients with severe disease and poor prognosis criteria (such as high D-dimer or high fibrinogen). It is clear that more studies are needed on this subject. Clinical characteristics of coronavirus disease 2019 in China COVID-19 and thrombotic or thromboembolic disease: implications for prevention, antithrombotic therapy, and follow-up High incidence of venous thromboembolic events in anticoagulated severe covid-19 patients Severe acute proximal pulmonary embolism and covid-19: a word of caution Acute occlusion of the abdominal aorta Acute aortic occlusion: a 40-year experience Acute aortic occlusiond factors that influence outcome Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study Journal of Vascular Surgery Cases and Innovative Techniques COVID-19 Related aortic thrombosis: A report of four cases Infection and Arterial Thrombosis: Report of three cases. Annals of vascular surgery The role of cytokines including interleukin-6 in COVID-19 induced pneumonia and macrophage activation syndrome-like disease Anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy Conflicts of interest: The authors certify that there is no conflict of interest with any financial organization regarding the material discussed in the manuscript FB: design, performed vascular surgery, writing of original draft BE: performed vascular surgery All authors read and approved the final version of the manuscript.