key: cord-0848046-vaeibzhv
authors: Kakamad, Fahmi H.; Abdullah, Hadi M.; Mohammed-Saeed, Dana H.; Hussein, Dahat A.; Mohammed, Shvan H.; Abdulrahman, Binar B.; Mirza, Aram J.; Abdulla, Berwn A.; Rahim, Hawbash M.; Rashid, Mohammed J.; Mohammed-Al, Farhad F.; Salih, Abdulwahid M.
title: Large vessel thrombosis in patient with COVID-19, a case series
date: 2020-11-12
journal: Ann Med Surg (Lond)
DOI: 10.1016/j.amsu.2020.11.030
sha: 0e9ca3ea30e8289e7721e903c145c164877c666c
doc_id: 848046
cord_uid: vaeibzhv

INTRODUCTION: Involvement of the large vessels is rarely reported and poorly understood in cases of Corona virus disease-19 (COVID-19). The aim of this study is to present a series of cases with large vessel thrombosis (LVT). METHODS: This is a multicenter prospective case series study. The participants were consecutive in order. All the patients were diagnosed as cases of COVID-19 with documented LVT were included in the study. Large vessels were defined as any vessel equal or larger than popliteal artery. The mean duration of follow up was 4 months. RESULTS: The study included 22 cases, 19 (86.4%) cases were male, 3 (13.6%) patients were females. The age ranged from 23 to 76 with a mean of 48.4 years. Four (18.2%) cases had pulmonary embolism confirmed by IV contrast enhanced chest CT scan. All of the cases showed pulmonary parenchymal ground glass opacities (GGO) and high D-Dimers (ranging from 1267 to 6038 ng/ml with a mean of 3601 ng/ml). CONCLUSION: COVID-19 is a hidden risk factor of LVT that may endanger the patient's life and lead to major amputation. Despite therapeutic anticoagulants still all COVID-19 patient are at risk for LVT, a high index of suspicion should be created and with minimal symptoms surgical consultation should be obtained.

J o u r n a l P r e -p r o o f Introduction Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is an emerging and novel pathogen which is easy to spread with variable duration of asymptomatic period causing major quarantines including enormous cities, towns, villages and public quarters all around the world. Although it is primarily reported as an infection of the respiratory system, pooled data revealed that it is a systemic illness that involves several body parts, including neurological, hematopoietic, gastrointestinal, immune, and cardiovascular systems [1, 2] . This wide range of presentations might be explained by the extensive and rich presence of angiotensin converting enzyme 2 (ACE2) in various organs [3, 4] .

Involvement of the large vessels is rarely reported and poorly understood. The aim of this study to present a series of cases with LVT due to COVID-19.

The study was registered in light of declaration of Helsinki -"Every research study involving human subjects must be registered in a publicly accessible database before recruitment of the first subject". The research was recorded in Chinese Clinical Trial Registry. The registration number is ChiCTR2000038537, the link is http://www.chictr.org.cn/showprojen.aspx?proj=60821&fbclid=IwAR3WPzY9Y91ggJZn1H-O9Avq-7HmQs-IOhChG-B4F2jTtAeH0CdbRVL2zX8

This is a single center prospective case series study. The participants were consecutive in order.

The paper has been written in line with the PROCESS criteria [8] .

The cases were managed in the governmental and private settings. The research was carried out during 7 months (from 1/1/2020 to 1/8/ 2020. The data were collected from the patients, patient's family and the hospital records. The cases were followed up for a mean duration of 4 months ranging from 2 months to 8 months. Ethical and scientific approval has been taken from the ethical committee of university of Sulaimani.

Participants: All Patients diagnosed as cases of COVID-19 either by nasopharyngeal swab or chest CT scan with documented LVT were included in the study. Large vessel was defined as any vessel equal or larger than popliteal artery. The exclusion criteria were: (1) Any patient without intraoperative findings showed total occlusion of the superior mesenteric artery with bowel ischemia, they underwent bowel resection with revascularization using greater saphenous vein (superior mesenteric-aorta and superior mesenteric-external iliac artery bypass) 

Although thromboembolic complications associated with COVID-19 have rarely been defined in details in the literature. It is known that the incidence of both venous and arterial thromboembolism increases in COVID-19 patients [5] . One of the most constant biochemical changes is D-dimer elevation which, to some extent certainly mirrors intra-vascular thrombosis in patients with COVID-19 [6] . All of the current cases showed elevated D-dimer.

The association between hypercoagulability and COVID-19 infection has been just highlighted in few studies. Tang et al revealed that abnormal coagulation findings, described as a evidently raised D-dimer level and fibrin degradation products (FDP), are prevalent in died cases of COVID19-related pneumonia [7] . Han and associates found that the coagulation process is considerably disturbed compared with uninfected control group and that observing coagulation parameters could lead to early recognition of the severe cases [9] . Intravascular thrombosis in COVID-19 is probably due to hypoxia, increased production of tissue factor, amplification of the coagulation cascade, diffuse intravascular coagulation (DIC), excessive inflammation and immobilization [5] .

The high prevalence of pulmonary embolism could be explained by two processes in addition to the mentioned factors: first, changed blood flow in response to the parenchymal process in hypoxia, and second, transition from deep venous thrombosis to pulmonary embolism, which, in fact, is the minority of the cases [10] . with LVT, 18 of them (90%) were male [13] . Escalard et al published their experience with 10 COVID-19 patients, only two of them (20%) were female [14] . In the current study, one patient (10%) was woman. Higher rate of thromboembolism in male COVID-19 patients is not understood, further studies are mandatory.

According to the recommendations from American Society of Hematology, all admitted COVID-19 patients should have thromboprophylaxis with fondaparinux or low molecular weight heparin (LMWH), and full therapeutic anticoagulation is required in patients with vessel thrombosis.

LMWH seems to be linked with a better prognosis in severe COVID-19 patients with noticeably raised D-dimer levels [15] .

In conclusion; COVID-19 is a hidden risk factor of LVT that may endanger the patient's life and lead to major amputation.

Source of Funding: none to be declared.

Conflict of interest: none to be declared.

The data that support the findings are available from the corresponding author, upon request. 

Hematological findings and complications of COVID-19

Severe refractory COVID-19 patients responding to convalescent plasma; A case series. Annals of medicine and surgery

COVID-19 and thrombotic or thromboembolic disease: implications for prevention, antithrombotic therapy, and follow-up: JACC state-of-the-art review

Venous and arterial thromboembolic complications in COVID-19 patients admitted to an academic hospital in

Thrombosis and COVID-19 pneumonia: the clot thickens!

Acute pulmonary embolism in COVID-19 patients on CT angiography and relationship to D-dimer levels

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

For the PROCESS Group. The PROCESS 2018 Statement: Updating Consensus Preferred Reporting of CasE Series in Surgery (PROCESS) Guidelines

Prominent changes in blood coagulation of patients with SARS-CoV-2 infection. Clinical chemistry and laboratory medicine

Incidence of thrombotic complications in critically ill ICU patients with COVID-19

Acute lower limb ischemia as clinical presentation of COVID-19 infection. Annals of Vascular Surgery

Case report: COVID-19 in a female patient who presented with acute lower limb ischemia

Acute limb ischemia in patients with COVID-19 pneumonia

Treatment of Acute Ischemic Stroke due to Large Vessel Occlusion With COVID-19: Experience From Paris

Acute upper limb ischemia Author contribution Please specify the contribution of each author to the paper, e.g. study design, data collections

Surgeons and physician supervising the management, revising the manuscript

Othman: data collection, drafting the manuscript

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None to be declared.

None is found.

Ethical approval was given by Ethical and Scientific Committee of University of sulaimani. No. 45

Please enter the name of the registry and the unique identifying number of the study. You can register your research at http://www.researchregistry.com to obtain your UIN if you have not already registered your study. This is mandatory for human studies only.ChiCTR2000038537 from Chinese Clinical Trial Registry.

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J o u r n a l P r e -p r o o f