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Background A paradigm shift appears to be occurring with overwhelming evidence of trans-radial access (TRA) being a safe and feasible approach for peripheral interventions compared to trans-femoral access (TFA). Our study explores the additional, multifactorial benefits of TRA regarding perioperative times, radiation, contrast administration, and cost-savings for patients and hospitals during Covid era. Methods A retrospective review of all peripheral interventions were performed over two years to outline the advantages and limitations of TRA compared to TFA approach. Patient demographics, procedural time, contrast usage, and radiation dose were recorded and analyzed. Hospital discharges and bed utilization were also studied. Results Total of 170 procedures performed via radial access were evaluated and compared to a control population of n=20 femoral access procedures. Procedural success rate for all interventions was 100% with 10% of cases presenting with acute limb ischemia and 90% presenting with chronic limb ischemia. A two-fold decrease in procedural time for TRA was evident in our analysis compared to the procedures conducted via TFA (81 +/- 43 mins vs. 164 +/- 36 mins, respectively). Furthermore, contrast usage and radiation absorption in TRA procedures decreased dramatically, adding to the potential cost-saving and safety measures for the patient and hospital system. Conclusion While current TRA limitations include operator experience, length of devices, and sheath sizes, the overall benefits of TRA over traditional TFA management cannot be ignored. TRA approach is undoubtedly a safe, feasible, efficient, and cost-saving route for peripheral interventions. It is here to stay as the present and future of diagnosing and treating peripheral arterial disease.Copyright © 2023 American College of Cardiology Foundation
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Case Report Restless legs syndrome (RLS) is a poorly understood underdiagnosed neurological, sensorimotor disorder. RLS arises from central nervous system dysfunction leading to both sensory and motor symptoms. Limited cases of COVID-19 vaccines related neurological sequelae, such as Guillain-Barré syndrome (GBS), have been reported. Case presentation A 77-year-old male patient with a past medical history of well-controlled hypertension, diabetes mellitus, hypothyroidism, coronary artery disease status post percutaneous coronary intervention, obstructive sleep apnea on CPAP at night, and restless leg syndrome diagnosed 20 years ago, presented complaining of a 3-month history of worsening of his restless leg symptoms although being compliant with his medications 2 weeks after his 2nd dose of Moderna vaccine. He stated that the frequency and severity of his symptoms had increased from 3-4 times a week lasting for minutes to a daily basis lasting for hours at night, had improved partially with exercise, and affected his sleep hygiene and daily morning activities. He requested several refills of his previously prescribed ropinirole. A comprehensive evaluation, including clinical examination, laboratory workup, brain computed tomography, and polysomnography was unremarkable. He was commenced on pramipexole 0.5 mg daily and instructed to follow up in the clinic in 3 months and call back with no improvement or worsening of his symptoms. Conclusion This case fulfilled the four essential features of RLS, urge to move, worsening with rest, improvement with exercise, and worsening in the evening. To date, no case of RLS associated with COVID-19 vaccines has been previously reported. Although COVID-19 vaccines are relatively safe, long-term complications should be monitored closely.
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Case Report The 2019 Novel Coronavirus (COVID-19) is currently causing a global pandemic. Common symptoms are fever, cough, myalgia, fatigue, headache, dyspnea, sore throat, vomiting, and diarrhea. Patients may present with end-organ failure, ARDS, shock, acute kidney injury, or even death. We present a case of COVID-19 with shortness of breath caused by an intra-cardiac thrombus. Case presentation An 84-year-old woman with COPD and diastolic heart failure presented with shortness of breath. She had hypoxemia on room air upon presentation. Lungs were clear on physical examination. COVID-19 PCR was positive. Her chest radiograph demonstrated no pulmonary infiltrates. Transthoracic echocardiography (TTE) demonstrated a large, irregularly shaped echogenic mass in both the right atrium and right ventricle consistent with a large thrombus. The mass in the right atrium was 3.9∗3.6 cm;the portion in the ventricle was 3.2∗2.2 cm. A previous TTE study in this patient did not reveal an intra-cardiac thrombus. No deep venous thrombosis was found. She was begun on anticoagulation and refused catheter-directed therapy. She improved and was discharged to her home. Discussion Thromboembolic complications of COVID-19 have been described in the literature. The most common are deep venous thrombosis and pulmonary embolism in critically ill patients despite the use of prophylactic anticoagulation. Several studies have reported post-mortem biopsies with widespread microthrombi. Arterial thrombosis with stroke and limb ischemia has also been described. Our case had an unusual presentation since the cause of her shortness of breath was the intra-cardiac thrombus. The pathogenesis beyond the hypercoagulability in COVID is not well understood. Some studies propose direct endothelial injury by the COVID-19 virus, causing microvascular inflammation, endothelial exocytosis, and endothelitis. Some experts propose a hypercoagulable state in COVID-19 patients based on elevated factor VIII, elevated fibrinogen, circulating prothrombotic microparticles, and neutrophil extracellular traps (NETs). Yet, no definitive mechanism has been identified. (Figure Presented).
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Introduction: The safety and feasibility of distal transradial access (TRA) is well-established for coronary interventions and has been increasingly used for peripheral angiography and intervention, especially with the increasing innovation and development of longer sheaths, balloons, and stent delivery systems. In the COVID-19 era, the emphasis on same-day discharge has led our institution to approach complex and challenging transfemoral cases through a transradial approach with favorable results. Methods: This is a retrospective review of cases deemed as complex femoral access due to the presence of complete total occlusion (CTOs), limited by patient body habitus or patients with prior endovascular aortic repairs (EVARs), and, thus, necessitated a TRA approach. Details of the patient characteristics and procedure were collected and evaluated. Results: Fifty-four patients underwent ultrasound-guided radial access. The average age was 67 ± 10 years, with 43 patients presenting with critical limb ischemia (Rutherford class 4). The mean height was 173 ± 9 cm and the mean body mass index was 30 ± 4.9 kg/m2. All patients underwent angiography through a transradial approach: 37% of patients had undergone intervention, with the majority of target vessels being iliac and/or femoral arteries;19% of patients were known EVARs with occluded graft limbs, and 22% had occluded surgical grafts. All patients received balloon angioplasty, 55% received mechanical aspiration thrombectomy or atherectomy, and 15% received stenting. The average procedure time was 88 ± 43 minutes with average contrast used of 179 ± 80 ml. The majority of patients were discharged the same day with an outpatient follow-up at one week. Conclusion: Our experience has emphasized the utility, efficacy, and safety in approaching peripheral interventions through distal radial access in obese patients with difficult, unfavorable transfemoral access, allowing same-day discharge and an economically feasible result.
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Background Cardiac muscle injury has been described as a known consequence of coronavirus-2019 (COVID-19) with poor clinical outcome. We aim to study the correlation between myocardial muscle injury and specific echocardiographic findings and, hence the association with mortality. Methods We conducted a retrospective cohort at the University Medical Center in Lubbock, Texas, under IRB of L20-172. We included COVID-19 patients from March 2020 until July 2020 who had transthoracic echocardiography (TTE) during their hospital admission. Myocardial muscle injury was defined by elevated troponin. Results A total of 101 patients were included. The mean age was 60 years, and 69.3 % were males. A total of 66 patients had a myocardial injury. Patients with myocardial injury had higher mortality than those without myocardial injury with a P-value of < 0.05, and this value remained significant after running a multiple regression analysis model. Only 4 patients had an ejection fraction of less than 40%. 11 patients had pericardial effusion. Only 4 patients had tricuspid annular plane systolic excursion (TAPSE)<1.5 cm. The mortality rate was 29.7%, and only 6 patients developed acute myocardial infarction. No difference was found between the two groups regarding the different echocardiographic findings. Conclusion Patients with COVID-19 and myocardial injury had higher mortality than those without myocardial injury with no difference regarding the different echocardiographic findings. [Formula presented]
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SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: COVID-19 (SARS-CoV-2) is causing a current pandemic. It commonly manifests with fever, dyspnea, and cough. Few COVID-19 patients with Guillain-Barré Syndrome (GBS) have been reported. The severe inflammatory response and the critically-ill nature of many COVID-19 patients is a challenge to distinguish GBS from critical illness polyneuropathy and myopathy. We present a COVID-19 patient complicated by GBS. CASE PRESENTATION: A 60-year-old woman presented with fever, cough, myalgia, and dyspnea for 10 days. A swab for SARS-CoV-2 RT-PCR was positive. CT chest revealed bilateral “ground-glass” opacities. She was started on oxygen, azithromycin, and hydroxychloroquine. Three weeks later, she developed bilateral symmetrical LE numbness and weakness that progressed to UE. Respiratory status worsened with increasing O2 requirements. Neuro exam showed weakness (2/5) in LE and (3/5) in UE. Respiratory muscle testing demonstrated a NIF of -35 cm H2O and an FVC of 1.7 L. MRI spine showed contrast enhancement of cauda equina nerve roots (Fig 1). CSF analysis revealed cytoalbuminologic dissociation (CAD) with 197 mg/dL of proteins and 0 WBC. She was diagnosed with GBS and started on intravenous immunoglobulin (IVIG) 0.4g/Kg/day for 5 days. After a week of therapy, the patient improved, recovered from COVID-19, and was discharged home. DISCUSSION: GBS is a disorder in which the immune system attacks gangliosides on the peripheral nervous system. It presents with ascending weakness and can cause total body paralysis and respiratory failure in severe cases. It is associated with a variety of viral and bacterial infections. 12 cases of GBS have been reported in COVID-19 infection. GBS developed within 10 days of COVID diagnosis and presented with ascending progressive, flaccid quadriparesis. All except 2 patients underwent CSF analysis and 91% showed CAD. IVIG was used for all the patients, and one was started on plasmapheresis. The involvement of the PNS supports the coronavirus neurotropic invasion pathway. It is still unclear if SARS-CoV-2 can directly invade neurons and cause neuropathy. We could not test for SARS-CoV-2 in CSF in our case, but the absence of WBC in the CSF indicated an immune response typically seen in GBS rather than direct neuronal invasion, in which pleocytosis is expected. MRI usually showed contrast enhancement of cauda-equina nerve roots due to radicular irritation. CSF showing CAD is usually observed in the second week after symptom onset. IVIG is preferred over plasmapheresis for treating GBS due to fewer side effects. However, thrombotic events occur in 1–16.9%. All of the reported COVID-19 cases with GBS, including our case, received IVIG, and none of them reported thrombotic events. CONCLUSIONS: Our case emphasizes that GBS should be considered as one of the differentials in patients with COVID-19 patients with ARDS, polyneuropathy, and difficulty weaning off ventilator. Reference #1: 1. Sedaghat, Z. and N. Karimi, Guillain Barre syndrome associated with COVID-19 infection: A case report. J Clin Neurosci, 2020. Reference #2: 2. Zhao, H., et al., Guillain-Barre syndrome associated with SARS-CoV-2 infection: causality or coincidence? Lancet Neurol, 2020. 19(5): p. 383-384. Reference #3: 3. El Otmani, H., et al., Covid-19 and Guillain-Barre syndrome: More than a coincidence! Rev Neurol (Paris), 2020. DISCLOSURES: No relevant relationships by Somedeb Ball, source=Web Response No relevant relationships by Tulio Bueso, source=Web Response No relevant relationships by Saif El Naser El Nawaa, source=Web Response No relevant relationships by Mohamed Elmassry, source=Web Response No relevant relationships by Ximena Solis, source=Web Response No relevant relationships by Victor Test, source=Web Response