key: cord-0907176-qeqq3kwb
authors: Powezka, Katarzyna; Khan, Taha; Narlawar, Ranjeet; Antoniou, George A.
title: Ruptured popliteal artery aneurysm complicated with ARDS secondary to SARS-CoV-2 infection
date: 2020-05-15
journal: Ann Vasc Surg
DOI: 10.1016/j.avsg.2020.05.012
sha: f41f32375ebf047a7bf0d5618697796371cd87d5
doc_id: 907176
cord_uid: qeqq3kwb

We herein report a rare case of the ruptured popliteal artery aneurysm in an 89 year old male, whose recovery after surgical treatment was complicated with acute respiratory distress syndrome (ARDS) secondary to confirmed infection with SARS-CoV-2. Presenting symptoms, patient’s comorbidities and postoperative course complicated with cardiac and respiratory failure leading to adverse outcome are discussed in this case report.

Popliteal artery aneurysms (PAAs) account for more than 80% of all peripheral arterial aneurysms 42 with prevalence in men (1, 2) . PAA is the most often treated extracranial aneurysm (apart from the 43 aorta), and thus constitutes an important clinical condition (3,4). The most common complications 44 encompass distal embolization and thrombosis, leading to acute or chronic limb-threatening 45 ischaemia. Rupture of PAA is rare and accounts for between 2% to 5% of cases in large series (5). It 46 mainly occurs in large or septic aneurysms, as well as, many years after successful surgical exclusion (6). 48

Herein, we present a case of ruptured PAA leading to acute limb ischaemia in a patient who 49 developed rapidly progressing chest infection secondary to SARS-CoV-2 infection. 50

Coronavirus disease 2019 (COVID-19) is a respiratory disease caused by SARS-CoV-2. Clinical 51 manifestation of COVID-19 varies from asymptomatic, acute respiratory distress to pneumonia of 52 varying degrees of severity (7). It primarily spreads through respiratory tract by droplets, respiratory secretions, and direct contact. COVID-19 is deemed to be highly contagious during its latency period 54 and is highly transmittable in humans. Its median incubation period has been estimated to be 3 days 55 but can be as long as 24 days (7,8). 56

Case report cough. SARS-CoV-2 was suspected and later confirmed on throat swabs. Repeated blood results 96 revealed WBC count of 5.2 10*9/l with lymphocyte count of 0.3 10*9/l. In view of his medical 97 background, a multidisciplinary team decision (including his daughter and geriatrician) was made 98 that ceiling of care would be limited to level I ward based care. His condition started deteriorating 99 rapidly and he, sadly, passed away on day six after his amputation due to acute respiratory distress 100 syndrome (ARDS), which was diagnosed in accordance to berlin criteria, inflicted with SARS-CoV-2 morbidity and mortality. A primary amputation has been described as the last resort in cases where 105 arterial reconstructive surgery is not possible or considered high risk, and was reported in three out 106 of 48 cases (6.25%) in a recent systematic review of the literature (10). 107

In the presented case, the endovascular approach was not appropriate due to occluded runoff 108 vessels and unsuitable anatomy. The only remaining options for invasive intervention were open 109 repair with a bypass or a major amputation. Due to his comorbidities, he was at high risk of mortality 110 from prolonged surgery, so (as he was keen on intervention) the decision was made to proceed with 111 the above knee amputation. 112

Emerging evidence shows that advanced age, underlying comorbidities, such as cardiovascular 113 disease, diabetes mellitus, cancer and COPD, are independent risk factors of adverse outcomes in 114 SARS-CoV-2 infections (11,12). The three primary symptoms of COVID-19 are fever, cough, and 115

shortness of breath. Symptoms may appear within a varying timeframe after exposure (from 2 days 116 to 14 days). The most common COVID-19 related complications encompass ARDS (29%), viremia 117 (15%), acute cardiac injury determined by elevated high sensitivity troponin (12%) and secondary 118 infection (10%) (11). Moreover, emerging evidence suggests a correlation between cardiac events, 119 such as myocardial infarction, myocarditis and heart failure, and infection with SARS-CoV-2, resulting 120 in adverse outcomes (13). 

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Acute respiratory distress syndrome

Ruptured popliteal artery aneurysms

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Duanyang Zhang et al Lymphopenia predicts disease severity of COVID-19 : a 179 descriptive and predictive study