key: cord-1026665-6h2bjz8j
authors: Palumbo, Diego; Guazzarotti, Giorgia; De Cobelli, Francesco
title: SPONTANEOUS MAJOR HEMORRHAGE IN COVID-19 PATIENTS: ANOTHER BRICK IN THE WALL OF SARS COV 2-ASSOCIATED COAGULATION DISORDERS?
date: 2020-06-24
journal: J Vasc Interv Radiol
DOI: 10.1016/j.jvir.2020.06.010
sha: c0038aa41f7b09fa9017ef3f353603c01bcc33b1
doc_id: 1026665
cord_uid: 6h2bjz8j

nan

This report was approved by the Ethics Committee at XXX Hospital (XXX, XXX).

Among the 818 consecutive patients admitted to our emergency department between March 1 st and April 30 th , 2020, with a positive nasopharyngeal swab test for SARS CoV 2 (Severe Acute Respiratory Syndrome Coronavirus 2), 16 (1.9%) suffered from at least one severe arterial bleeding episode, defined as any imaging proven, clinically overt sign of arterial hemorrhage coupled with a drop in hemoglobin count ≥ 3 mg/dL and requiring intervention. A single patient (1/16, 6.2%) was excluded due to an iatrogenic hepatic injury, bringing the incidence of spontaneous hemorrhage to 1.8% (15/818 [1/15, 6 .7%] and internal thoracic artery [1/15, 6 .7%]). The typical angiographic pattern (found in 12/15 patients, 80%) consisted of multiple, tiny bleeding foci affecting distal vascular territories [ Fig.1 ]. Considering this peculiar bleeding pattern and the critical conditions of most patients, embolization with polyvinyl alcohol particles of the entire arterial segment accountable for the hemorrhage was usually performed. Technical and complete clinical success was achieved in all patients; no procedure related complications were recorded [1] .

The origin of severe hemorrhage in COVID-19 patients is unclear. Prophylactic antithrombotic treatment has been established as a well-known risk factor; however, the reported incidence of major spontaneous hemorrhage in general patients receiving LMWH at prophylactic dosage is less than 1% [2] , below the disease-specific incidence observed in our population (1.8%). Possible explanation could lie in the pathophysiology of SARS CoV 2 infection, which is characterized by an increase of proinflammatory cytokines in serum (systemic cytokine storm), directly correlated with both disease severity and subtle coagulation disorders. Furthermore, widespread endothelial cell damage has been hypothesized to occur [3] . Functional implications of this pathogenic mechanism include diffuse microvascular damage with both a substantial component of microvascular thrombosis (microCLOTS hypothesis [3] ) and

imbalances in platelet recruitment. The latter could then result in multiple bleeding foci typically affecting distal microcirculation, as suggested by our observations and confirmed by pathological findings [4] , and occurring late in the disease course (median time in bleeding onset: 23 days).

In conclusion, major spontaneous hemorrhage represents a quite uncommon, but dramatic complication of SARS CoV 2 infection, possibly representing the other, less renowned side of disease-specific coagulation disorders. Failure to acknowledge such a risk could significantly worsen the prognosis of patients with COVID-19.

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