key: cord-0985541-e2fcrtkq
authors: Lucatelli, Pierleone; Rocco, Bianca; Nardis, Pier Giorgio; Cannavale, Alessandro; Bezzi, Mario; Catalano, Carlo; Corona, Mario
title: Bleeding in COVID Patients: What We Have Understood So Far
date: 2021-01-28
journal: Cardiovasc Intervent Radiol
DOI: 10.1007/s00270-021-02775-8
sha: 4baaa565969fb8534ff664e7791daae8fb76e95c
doc_id: 985541
cord_uid: e2fcrtkq

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Spontaneous soft tissue hematoma (SSTH) is a wellknown and potentially life-threatening complication of anticoagulation therapy. Interventional radiology management (transarterial embolization, TAE) of patients with SSTH is not codified by international guidelines and is usually offered to patients with hemodynamic instability or failure of medical management [4] .

To date, no evidence exists on which COVID-19 patients should be offered TAE. Patients selection is particularly challenging for several reasons: (I) COVID-19 population encompass elderly fragile patients with multiple coagulations disorders; (II) heparin is considered an essential therapy in order to limit COVID-19 vascular lifethreatening complications. In this scenario, the reduction of administered heparin dose or either its suspension has to be balanced with the clinical general conditions and the severity of the bleeding.

In order to understand the appropriate timing of TAE, we share the experience of our Interventional Radiology Unit in the management of COVID-19 bleedings.

Between 15 September and 20 December 2020, we have been consulted for 21 COVID-19 patients undergoing therapy with heparin, for hemoglobin drop (mean Hb drop: 1.6 g/dL) and evidence of SSTH. A multiphasic contrastenhanced CT showed SSTH located in the rectus sheath (3/ 21), iliopsoas muscle (11/21, with retroperitoneal hemorrhage in 6/10), thoracic wall (4/21) and thight (3/21).

In patients with hemodynamic instability, active blush at CT scans and Hb drop [ 2 Hb g/dL, immediate superselective TAE was performed (14/21) permitting bleeding stop and recovery of treated patients in 12/14; two death due to bleeding-related cardiovascular failure occurred in this subgroup ( However in the remaining 7/21 patients, an attempt of conservative management was opted. After a median time of 2 days, all except one patient (6/7) were referred to angiography due to persistent Hb drop; moreover, 2/7 died due to bleeding-related cardiovascular failure (28.6%). This evidence supports that prompt angiographic management should be preferred.

Several technical aspects of TAE procedures should be underlined.

Superselective DSA depicted active blush only in 14/20 procedures; empiric embolization was performed based on the site of hematoma in 5/20 procedure, and in 1/20, no embolization was performed (requiring a second angiography 3 days later). These findings suggest that embolization should be performed even without sign of active bleeding.

TAE was performed with gelfoam alone (4/19; 21%), gelfoam and coil (12/19; 63.2%), and glue (2/19; 10.5%). Coils were employed as a sole embolic agent in 1/19 procedure (5.3%; Fig. 1 ). This patient rebled promptly requiring adjunctive TAE with coils and gelfoam (Fig. 2) . This occurrence suggests adding embolic agents (gelfoam/ glue) in combination with coils to facilitate blood stasis and consequent clot formation. Moreover, during severe bleeding vasospasm may impede appropriate coil sizing and positioning; finally, multiple transfused patients are more likely to experience coagulation dysfunction [5] that could impair appropriate clot formation.

Concluding our impression on the interventional management of COVID-19 SSTH bleeding is that nearly all attempts to proceed with a conservative management failed, thus differing with non-COVID-19 SSTH; selective embolization should be performed even without sign of TAE showed blood flow through the previously embolized lumbar artery (coils; circle) with sites of bleeding (harrow head). C Embolization was performed with coils and gelfoam, achieving sustained blood stasis, permitting patient recovery active bleeding; finally, adjunctive embolic agent (gelfoam /glue) employment is strongly suggested to facilitate clot formation.

Funding None.

Conflict of Interest The authors declare that they have no conflict of interest.

Heparin as a therapy for COVID-19: Current evidence and future possibilities

Spontaneous soft tissue hematomas

Heparin-related major bleeding in Covid-19-Positive patient: perspective from the outbreak

Transcatheter arterial embolization of spontaneous soft tissue hematomas: a systematic review

The European guideline on management of major bleeding and coagulopathy following trauma: fifth edition. Crit Care