Acute aortic thrombosis in a patient with SARS-CoV-2 coronavirus disease (COVID-19).

One of the rare and life-threatening conditions is acute aortic thrombosis. We have described a case of thrombosis of the aorta and iliac arteries in a patient against the background of viral pneumonia COVID-19, with newly diagnosed diabetes mellitus and arterial hypertension.Copyright © 2021 The authors. All right reserved.

Abdominal Aortic Occlusion in Setting of Covid-19

Introduction: The incidence of arterial thrombosis among critically ill patients with COVID-19 is 4.4%, acute aortic obstruction alone having a mortality rate of 31%. We present a review of the literature regarding isolated abdominal aortic thrombosis (IAAT) in the setting of COVID-19 infection, as well as a case presentation. Method(s): A literature review was performed using Pubmed with the keywords, aorta, aortic, thrombus, and Covid-19. Within these articles, the scope was narrowed to articles that related to IAAT in the setting of Covid-19 infection. Result(s): Our literature review found 9 articles detailing a total of 11 cases of IAAT in the setting of COVID-19 infection. IAAT had a mortality 22% (2 out of 9 patients). Approximately, 55% (6 out of 11) of the patients were treated with surgery and 27% (3 out of 11) received anticoagulation. 73%, (8 out of 11) of the patients in our literature review presented with symptoms of acute limb ischemia. Ages ranged from neonate to 85 years old, though 82% (9 out of 11) were over the age of 50. Conclusion(s): Our literature review suggests that IAAT is a serious complication of COVID-19 infection. IAAT is more common in males and people over the age of 50, which aligns with the 52 year- old male patient who presented to our clinic with lower extremity claudication and bilateral 1st & 5th toe cyanosis after COVID-19 infection. To prevent devastating limb ischemia, we emphasize early evaluation of claudication symptoms in patients with COVID-19 or recent COVID-19 infection.

Acute ischemic stroke due to floating thrombus of ascending aorta: An acute and subacute complication of SARS-CoV-2 infection

Objective: To describe ischemic stroke due to floating thrombus of ascending aorta occurring as acute and subacute complication of SARS-CoV-2 infection. Material(s) and Method(s): consecutive identification in clinical practice of ischemic strokes secondary to aortic arch thrombosis and history of acute or recent Covid-19 infection. Result(s): two patients had ischemic stroke with evidence of aortic arch thrombosis. The first case had concomitant acute Covid-19 infection, the second had recent Covid-19 infection. Both patients underwent intravenous thrombolysis, and subsequent anticoagulation. One patient died due to cerebral hemorrhage. Discussion and Conclusion(s): aortic arch thrombosis can be an incidental finding in acute ischemic stroke in patients with concomitant and recent COVID-19 disease. However, the infection may lead to thrombosis in non-atherosclerotic vessels and to cerebral embolism. Our findings support active radiological search for aortic thrombosis during acute stroke in patients with acute or recent COVID-19 disease.Copyright © 2022

A Persistent Nightmare: A Case of Recurrent Brachial Artery Thrombosis

Background Brachial artery thrombosis can be seen with thromboembolism, hypercoagulability, and arterial thoracic outlet syndrome. Case A 33-year-old healthy female construction worker presented with right hand discoloration and pain. She suffered a COVID-19 infection 8 weeks prior with hand symptoms developing shortly thereafter. She could no longer work due to the pain. Duplex ultrasound and CTA of the right upper extremity (Figure) demonstrated localized thrombosis of the right brachial artery. The workup yielded no aortic or intracardiac thrombus, and cardiac event monitor showed no atrial arrhythmia. She underwent thrombectomy with brachial artery stenting and was found, during surgery, to have distal ulnar artery occlusion. Two days post-op, she had recurrent pain and was found to have brachial artery recurrent thrombosis. She underwent urgent brachial-brachial bypass. Arm pain continued despite graft patency, so ulnarpalmar bypass was performed. Decision-making Hypercoagulability workup, including antiphospholipid antibody, protein C, protein S, homocysteine, and Lp(a), was negative. Neither central thrombus on TEE nor evidence of thoracic outlet syndrome was found. As a diagnosis of exclusion, brachial artery thrombosis was ascribed to COVID infection. Despite rivaroxaban, the patient developed gangrene (Panel C) requiring partial digit amputation. Conclusion We present a case of COVID-19-induced recurrent brachial artery thrombosis despite surgical intervention. [Formula presented]Copyright © 2023 American College of Cardiology Foundation

Single-Center Experience with Simultaneous Mural Aortic Thrombosis and Peripheral Obstructive Disease in Pre-COVID-19 and COVID-19 Era.

BACKGROUND: Mural aortic thrombosis associated with chronic peripheral obstruction of the lower limbs is an unusual event. Repeated embolism of instability aortic mural thrombosis caused acute limb ischemia (Rutherford 2 classification) in patients with peripheral arterial disease (PAD). We report a single-center experience for patients with transmural aortic thrombosis and peripheral artery disease. METHODS: We retrospectively analyzed data of 54 patients with aortic mural thrombus disease with PAD presentation, treated at our center between 2013 and 2022. RESULTS: Thirty patients (six with proven SARS-CoV-2 infection) underwent hybrid or staged treatment for an aortic lesion and for lower limb ischemia, by the placement of an endovascular aortic stent graft and a femoro-distal or a popliteal-distal bypass graft. The remaining 24 cases were only subjected to an intravascular treatment of the thoracic or abdominal aorta. Transient renal failure occurred in three patients. No embolic events were detected during the procedures. Aortic-related mortality was reported in just one patient who died from multiple organ failure. There was an embolic stroke in one patient with proven SARS-CoV-2 infection, three major amputations in patients with proven SARS-CoV-2 infection and no aortic-related mortality. CONCLUSIONS: Stent coverage of complex aortic lesions, alone or in association with a distal bypass graft, supports this approach in a variety of settings. The COVID-19 pandemic caused an increased mortality and amputation rate.

Renal artery thrombosis as a long-term complication of COVID-19

Coronavirus disease 2019 (COVID-19) has been extensively associated with microvascular and macrovascular thrombosis. Several reports have demonstrated a link between COVID-19 and pulmonary embolism, deep vein thrombosis, myocardial infarction, stroke, and aortic thrombosis. Renal artery thrombosis is of special interest because of its life-threatening consequences, such as acute kidney injury and renal infarction. We present a case of left renal artery thrombosis as a long-term complication of COVID-19. Moreover, we demonstrate the effectiveness of interventional radiology to regain vascularization of the affected kidney. © 2022

Outcomes of large arterial vessel thrombosis in the setting of COVID-19

Background: COVID-19 infection can cause an array of symptoms including arterial thrombosis with an incidence of 4.4% however isolated large vessel thrombosis is even rarer. We present a review of the literature regarding large vessel (Iliac and aortic) thrombosis associated with COVID-19 infection and discuss the outcomes. In addition, we present a case that was infected with COVID-19 with presentation of isolated aortic thrombosis. Method(s): We performed a literature review using Pubmed keywords, COVID-19, iliac, aortoiliac, aorta, thrombosis. The articles were then narrowed to the ones only pertaining to aortic (AT) or iliac thrombosis (IT) with COVID-19 infection. Result(s): Our literature review found 12 articles detailing a total of 14 cases of AT or IT in the setting of COVID-19 infection. Ages ranged from neonate to 85 years old. Incidence of smoking was 30% and diabetes was 25%. Mortality rate was noted to be 14% (2 out of 14 patients). Approximately, 50% (7 out of 14) of the patients were treated with surgery and 21% (3 out of 14) received anticoagulation. 64%, (9 out of 14) of the patients presented with symptoms of acute limb ischemia. Amputation rate was noted to be 7% (1 out of 14). Conclusion(s): Large vessel thrombosis caused by COVID- 19 infections seems to carry high mortality and amputation rates. To prevent devastating sequel of COVID infection with concurrent large arterial thrombosis we emphasize that physicians employ a high index of suspicion and urgent involvement of the vascular interventionists. The case that we presented emphasized the importance of understanding the effect of COVID-19.

Aortic thrombosis presenting as myocardial infarction in a child

Background: Ascending aortic thrombus is rare in children without history of trauma, hypercoagulable condition or vascular disease and carries a high mortality risk necessitating rapid identification and management. Aim(s): We aim to present the clinical course for a rare pediatric case. Method(s): We reviewed the medical record for a child with recurrent life-threatening thrombi. Result(s): A 12-year old previously healthy male presented with chest pain. ECG revealed ST segment elevation. Echocardiography revealed an ejection fraction of 25% and a mobile mass (10 x 20 mm) in the ascending aorta. COVID testing was negative. Troponin-I was elevated. He was emergently placed on cardiopulmonary bypass where a large organized thrombus was removed. The left anterior descending coronary artery was occluded. He underwent intracoronary tPA, aspiration thrombectomy and balloon angioplasty. Hypercoagulable and autoimmune work-up revealed elevated factor 8 activity, von willebrand factor (vWF) activity and thrombocytosis with increased function by viscoelastic testing (ROTEM). Myocarditis, cardiogenetics and genetic testing for thrombophilia were negative. He was discharged on heart failure therapy, triple anti-platelet therapy (aspirin, clopidogrel, dipyridamole) and apixiban. He underwent a heart transplant 5 months later. Three weeks post-transplantion, he was incidentally found to have a large left atrial thrombus. At this time, he was only on aspirin. Factor 8 activity at time of transplant and second thrombus discovery was >400%. vWF activity and platelet count were also elevated. ROTEM revealed elevated platelet and fibrinogen activity. He underwent left atrial thrombectomy and was restarted on triple antiplatelet therapy and apixiban. He has not had recurrence on this regimen for 8 months. Conclusion(s): Thrombocytosis and elevated pro-inflammatory coagulation factors may predispose to development of potentially fatal thrombi. Besides inflammation, etiology may be unknown, particularly in apparently healthy children, prompting additional research into potentially genetic conditions in these complex pathways to further elucidate patients at risk.

AORTIC THROMBUS DESPITE THERAPEUTIC DOSE OF ANTICOAGULATION IN A PATIENT POSITIVE FOR COVID-19

SESSION TITLE: Extraordinary Cardiovascular Reports SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: Hypercoagulability is a well-known complication of COVID-19, with the most common vascular events being pulmonary embolism and deep vein thrombosis (1). Arterial thrombotic events, specifically aortic thrombosis, are rarely observed in COVID-19 infections. Literature review reveals less than 10 cases of aortic thrombosis have been reported in patients with COVID-19 infection. Here, we report a unique case of acute aortic thrombosis despite administration of therapeutic anticoagulation. CASE PRESENTATION: A 77 y.o. female with no known medical history presented to the hospital after a diagnosis of COVID-19 five days prior. Upon arrival, she was hypoxic requiring supplemental oxygen via non-rebreather (NRB) mask. CT chest with contrast revealed bilateral ground-glass opacities without evidence of pulmonary embolism or aortic thrombus. She was treated with remdesivir, dexamethasone, baricitinib and enoxaparin 40mg BID (essentially therapeutic dosing based on patient's body weight of 45kg). Adequate oxygenation was maintained with nasal cannula and NRB. However, on day eight of admission she was noted to desaturate to 80% requiring BiPAP. D-dimer and CRP drastically increased from 0.36ug/ml to 1.75ug/ml and 13.0 to 102.2, respectively. Repeat CT chest with contrast revealed multiple intraluminal thrombi in the distal thoracic aorta. Treatment with clopidogrel was initiated, however patient remained BiPAP dependent. Due to DNR/DNI status, intubation was not pursued. Ultimately, patient was transitioned to comfort care and expired. DISCUSSION: Thrombotic events are poorly understood but remain a well-documented sequela of COVID-19 infection. The pathophysiology of thrombosis in COVID-19 patients has not been fully elucidated, however, it likely involves amplification of the hypercoagulable state due to viral infection. Some of the proposed theories regarding this effect include endothelial dysfunction secondary to direct virus invasion and immuno-thrombosis due to viral mediated endothelial inflammation with resultant platelet activation (2,3). Regarding COVID-19 associated arterial thrombi, myocardial infarction and stroke are the most commonly encountered events. The few reported cases of aortic thrombi occurred almost exclusively in males with significant cardiovascular risk factors and not on anticoagulation (1,3). CONCLUSIONS: Due to the increased risk of venous thromboembolic events, prophylaxis is routinely used in patients with COVID-19. However, in our case, the patient developed multiple aortic thrombi without any typical risk factors for endothelial lesions despite being fully anticoagulated. This case highlights the need for continued research and trials related to appropriate anticoagulation therapies in hospitalized patients with COVID-19. Additionally, physicians should be aware of potential arterial thrombi in patients infected with COVID-19. Reference #1: de Carranza M, Salazar DE, Troya J, et al. Aortic thrombus in patients with severe COVID-19: review of three cases. J Thromb Thrombolysis. 2021;51(1):237-242. doi:10.1007/s11239-020-02219-z Reference #2: Loo J, Spittle DA, Newnham MCOVID-19, immunothrombosis and venous thromboembolism: biological mechanismsThorax 2021;76:412-420. doi:10.1136/ thoraxjnl-2020-216243 Reference #3: Woehl B, Lawson B, Jambert L, Tousch J, Ghassani A, Hamade A. 4 Cases of Aortic Thrombosis in Patients With COVID-19. JACC Case Rep. 2020;2(9):1397-1401. doi:10.1016/j.jaccas.2020.06.003 DISCLOSURES: No relevant relationships by Chelsey Bertrand- Hemmings No relevant relationships by Alyssa Foster No relevant relationships by Kyle Foster No relevant relationships by Yelena Galumyan No relevant relationships by Veronica Jacome No relevant relationships by Viet Nguyen

WHEN ST-ELEVATION MYOCARDIAL INFARCTION (STEMI) IS JUST THE BEGINNING: DISSEMINATED INTRAVASCULAR COAGULATION (DIC) FROM COVID-19 INFECTION PRESENTING AS ACUTE MYOCARDIAL INFARCTION

SESSION TITLE: Cardiovascular Complications in Patients with COVID-19 SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: COVID-19 is associated with a hypercoagulable state and has been linked with Disseminated Intravascular Coagulation (DIC) [1]. DIC causes systemic thrombosis in micro- and macro- vasculature and in rare instances can involve coronary arteries [2]. In this case report, we present a patient who presented as an ST-segment elevation myocardial infarction (STEMI) and DIC in the setting of severe COVID-19 disease. CASE PRESENTATION: A 46-year-old lady with a history of hypertension presented with acute onset of typical chest pain. She tested positive for COVID-19 infection. Emergency room EKG showed anterior STEMI, and the patient underwent cardiac catheterization via a femoral approach which revealed a 99% stenosis in the proximal LAD, with filling defects consistent with a thrombus. Thrombectomy was performed and three drug-eluting stents were placed in the left anterior descending artery. Following stent placement, the patient went into ventricular fibrillation cardiac arrest followed by PEA. ROSC was attained after 3 rounds of CPR. Labs showed an acute drop in hemoglobin from 14 gm/dL to 5 gm/dL with CT evidence of extensive retroperitoneal bleed, extraperitoneal bleed, and large abdominal aorta thrombus proximal to the bifurcation. Labs were significant for prolonged INR (2.1), PT (23.4 seconds), PTT (106.7 seconds), elevated D-dimer (>4.0), decreased platelets (101K/μl), and increased fibrin split products (80uG/mL) consistent with DIC. The acute aortoiliac occlusive thrombus resulted in acute limb ischemia, rhabdomyolysis causing renal failure, and compartment syndrome requiring bedside fasciotomy. She was treated with triple therapy and demonstrated gradual clinical improvement. DISCUSSION: DIC was a possible precipitant of STEMI in this patient with evidence of thrombotic occlusion of LAD. DIC is a life-threatening coagulopathy characterized by mixed hypo- and hypercoagulation. This often leads to a systemic distribution of clots, evidenced by thrombi present in the coronary and aortoiliac arteries. Historically, bacterial sepsis was more strongly linked with DIC than viral causes;however, there has been an increasing amount of evidence linking COVID-19 with DIC, likely due to the severity of the illness. In this patient with recent stent placement, large aortic thrombus, and extensive retroperitoneal bleed, management was complicated by need for dual antiplatelet therapy for drug-eluting stents as well as anticoagulation for acute limb ischemia. Another diagnosis to keep in the differential includes heparin-induced thrombocytopenia, characterized by similar findings to DIC, but is associated with antibodies against platelet factor 4, which was not found in our patient. CONCLUSIONS: In this case, a young female patient without traditional cardiac risk factors was found to have an anterior STEMI, likely precipitated by DIC as a complication of COVID-19 infection. Reference #1: Asakura, Hidesaku, and Haruhiko Ogawa. "COVID-19-associated coagulopathy and disseminated intravascular coagulation.” International journal of hematology vol. 113,1 (2021): 45-57. doi:10.1007/s12185-020-03029-y Reference #2: M. Sugiura, K. Hiraoka, and S. Ohkawa, "A clinicopathological study on cardiac lesions in 64 cases of disseminated intravascular coagulation,” Japanese Heart Journal, vol. 18, no. 1, pp. 57–69, 1977. DISCLOSURES: No relevant relationships by radhika deshpande No relevant relationships by Shruti Hegde No relevant relationships by Robert Kropp No relevant relationships by Prashanth Singanallur

Aortic thrombosis as a dramatic vascular complication in COVID-19 disease.

OBJECTIVE: To report clinical outcomes of COVID-19 related acute aortic thrombosis (AAT). METHODS: Consecutive COVID-19 patients presenting with AAT between April 2020 and August 2021 were included retrospectively. Clinical and radiological data were prospectively collected. RESULTS: Ten patients (men, 90%; mean age, 64 ± 2 years) were included. At the time of AAT diagnosis, four patients were in intensive care unit. Median time between diagnosis of COVID-19 and AAT was 5 days [IQR 0-8.5]. Clinical presentation was acute lower limb ischaemia (n=9) and mesenteric ischaemia (n=2). Thrombus localization was the abdominal aorta (n=5), the thoracic aorta (n=2) or both (n=3), with the following embolic sites: lower limbs (n=9), renal arteries (n=3), superior mesenteric artery (n=2), splenic artery (n=1), cerebral arteries (n=1). Revascularization was performed in 9 patients, using open (n=6), endovascular (n=2) or hybrid techniques (n=1). Three patients required reinterventions. The 30-day mortality was 30%. Three major amputations were performed in two patients, resulting in a free-amputation survival rate of 50% after a median follow-up of 3,5 months [IQR 2-4.1]. CONCLUSION: AAT is a rare and devastating complication of COVID-19 disease, responsible for high mortality and amputation rates.

Acute ischemic stroke due to floating thrombus of ascending aorta: an acute and subacute complication of SARS-CoV-2 infection

Objective To describe ischemic stroke due to floating thrombus of ascending aorta occurring as acute and subacute complication of SARS-CoV-2 infection. Material and Methods consecutive identification in clinical practice of ischemic strokes secondary to aortic arch thrombosis and history of acute or recent Covid-19 infection. Results two patients had ischemic stroke with evidence of aortic arch thrombosis. The first case had concomitant acute Covid-19 infection, the second had recent Covid-19 infection. Both patients underwent intravenous thrombolysis, and subsequent anticoagulation. One patient died due to cerebral hemorrhage. Discussion and Conclusions aortic arch thrombosis can be an incidental finding in acute ischemic stroke in patients with concomitant and recent COVID-19 disease. However, the infection may lead to thrombosis in non-atherosclerotic vessels and to cerebral embolism. Our findings support active radiological search for aortic thrombosis during acute stroke in patients with acute or recent COVID-19 disease.

COVID-19 Associated Aortic Thrombosis Mimicking Transverse Myelitis

Objective: NA Background: COVID-19 associated thromboembolism has attained considerable interest in recent times. However, most studies focus on venous and pulmonary embolism only. We present a case of COVID-19 associated massive aortic thrombosis which presented as paraparesis mimicking transverse myelitis. Design/Methods: NA Results: This is a case of 42-year-old female presented with acute onset paraparesis with paraesthesia and back pain. She was provisionally diagnosed as a case of acute transverse myelitis. During evaluation she developed fever with respiratory distress. Her COVID RTPCR came positive, along with HRCT thorax showing evidence of viral pneumonia with severity score 13/25. She was shifted to COVID-19 facility and managed as per standard protocol. After stabilization, a repeat examination revealed discoloration in left lower limb which was also cold to touch. CT angiography revealed a massive thrombus in distal abdominal aorta extending up to left common iliac artery, while MRI Spine was normal. Patient was transferred to vascular surgery department for further management. To best of our knowledge this is first case reporting arterial thrombosis mimicking myelitis in COVID-19. Conclusions: To conclude, COVID-19 patients are susceptible to thrombosis and aortic thrombosis can mimic transverse myelitis in presentation.

Treatment of Symptomatic Paravisceral Aortic Thrombus Using Percutaneous Suction Thrombectomy

Objective: Paravisceral aortic thrombus in an otherwise normal aorta is rare. A hemodynamically significant thrombus burden in such patients can result in visceral malperfusion and bilateral lower extremity ischemia, both of which, historically, have a high mortality rate. Open thrombectomy via a thoracoabdominal approach is associated with high mortality. Other endovascular alternatives, including Fogerty embolectomy and mechanical thrombectomy, are associated with visceral embolization. The Penumbra CAT-12 lightning device (Penumbra Inc, Alameda, Calif) most commonly used to treat ileofemoral deep vein thrombosis is a 12F suction catheter with the ability to remove large amounts of clot burden with minimal blood loss owing to its sensor mechanism. The ability to suction thrombectomy-focused areas in the aorta reduces the likelihood of embolization. We have presented the cases of two patients with acute symptomatic paravisceral aortic thrombus who were treated with this device and their outcomes. Methods: Two patients had presented to the emergency room with acute onset abdominal pain and bilateral lower extremity rest pain and numbness. Patient 1 was a 46-year-old woman with antithrombin III and protein C deficiency (Fig 1). Patient 2 was a 78-year-old woman with recent coronavirus disease 2019 infection, chronic obstructive pulmonary disease, and congestive heart failure (Fig 2). Computed tomography angiography of patients demonstrated aortic thrombus in the paravisceral aorta extending from the supraceliac to the infrarenal aorta. Both patients underwent percutaneous suction thrombectomy of the aorta using the Penumbra CAT-12 lightning device. Patient 2 also underwent bilateral femoral cutdown, thrombectomy, and kissing iliac stents, followed by diagnostic laparoscopy without any further intervention. Results: The intraoperative angiographic images demonstrated the initial aortic thrombus in the paravisceral aorta with resolution of thrombus after suction thrombectomy (Figs 1 and 2). The abdominal pain and bilateral lower extremity rest pain had resolved in both patients postoperatively and did not require any further surgical intervention. Patient 1 was discharged home on postoperative day 3. Patient 2 was discharged to a rehabilitation facility on postoperative day 10. Conclusions: Percutaneous suction thrombectomy devices such as the Penumbra CAT-12 lightning device is effective in removing a large paravisceral aortic clot burden without any embolization to the visceral vessels. This is a newly available alternative to consider for such patients with symptomatic paravisceral aortic thrombus considered to have a high mortality risk with open intervention. [Formula presented] [Formula presented]

Aortic thrombosis leading to acute limb ischemia in the setting of COVID-19 pneumonia versus recently resolved pancreatitis

Case Report Hypercoagulability in the setting of COVID 19 infection is well known, but data about arterial thrombosis in this context is limited. There have also been rare instances of aortic thrombosis in the setting of acute pancreatitis. We present the case of a 64-year-old female who was admitted for acute hypoxic respiratory failure due to COVID pneumonia. A few days earlier, the patient was admitted for a bout of acute pancreatitis that was medically managed but left the hospital against medical advice. During this admission, she was found to be covid positive but was asymptomatic. Chest imaging showed bilateral interstitial opacities. The patient was readmitted due to worsening hypoxia and received dexamethasone, antibiotics and prophylactic heparin on admission. The patient didn't receive remdesivir due to acute kidney injury. Oxygen requirements increased over the next 2 days. On hospital day 3 , the patient developed right lower limb pain not relieved with analgesics with symptoms suggestive for acute limb ischemia. CT angiography of the abdominal aorta and lower extremities revealed significant clot burden in infrarenal aorta and acute occlusion of bilateral popliteal arteries and right profunda femoral artery likely due to aortic clot emboli. Vascular surgery was consulted and proceeded with thrombectomy in the infrarenal aorta, bilateral common iliac arteries and bilateral lower extremity arteries with compartment fasciotomy of the lower extremities. Unfortunately, the patient developed severe septic shock and passed away a few hours after the surgery. Although rare, there have been a few other case reports where aortic thrombosis was caused by COVID 19 or acute pancreatitis. In our patient, both pancreatitis and COVID 19 likely have played a role in aortic thromboembolism leading to critical limb ischemia. Once diagnosed, arterial occlusion is a medical emergency and needs urgent attention and immediate intervention! Physicians should be aware of the possibility of arterial occlusion in the context of Covid 19, especially if acute pancreatitis preceded Covid 19 infection.

Acute aortic thrombosis in a patient with SARS-CoV-2 coronavirus disease (COVID-19)

One of the rare and life-threatening conditions is acute aortic thrombosis. We have described a case of thrombosis of the aorta and iliac arteries in a patient against the background of viral pneumonia COVID-19, with newly diagnosed diabetes mellitus and arterial hypertension. © 2021 The authors. All right reserved.

A COVID-19 Patient with Simultaneous Renal Infarct, Splenic Infarct and Aortic Thrombosis during the Severe Disease.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has been associated with a high incidence of arterial and venous thrombotic complications. However, thromboembolic events in unusual sites such as limb and visceral arterial ischemia are reported rarely in the literature. Herein, we describe a rare case of a patient with severe coronavirus disease 2019 (COVID-19) infection who experienced severe abdominal pain during the hospitalization and presented simultaneously renal artery, splenic artery and vein as well as aortic thrombi despite prophylactic antithrombotic treatment. Information about his follow-up post discharge is also provided. This case report raises significant clinical implications regarding the correct dose of antithrombotic treatment during the acute phase of the severe COVID-19 infection and highlights the need for incessant vigilance in order to detect thrombosis at unusual sites as a possible diagnosis when severe abdominal pain is present in severe COVID-19 patients.

Aortic thrombosis in a neonate with COVID-19-related fetal inflammatory response syndrome requiring amputation of the leg: a case report.

Neonatal infection with SARS-CoV-2 is considered to have no major complications. A neonate with lower limb gangrene owing to spontaneous aortic thrombosis in the setting of a fetal inflammatory response syndrome (FIRS) post-intrauterine COVID-19 infection is presented. A healthy full-term newborn discharged from hospital on Day 3 developed irritability and progressive blackish discoloration of the toes of the right lower limb on Day 6 of life. Doppler imaging revealed acute thrombosis of the abdominal aorta with a critically ischaemic right lower limb. On Day 11 of life, SARS-CoV-2 RT-PCR was negative but total antibodies (IgG and IgM) were positive in both mother and neonate. The neonate showed raised inflammatory markers including CRP, ESR, interleukin-6, procalcitonin, ferritin and LDH along with elevated N-terminal pro-brain natriuretic peptide and D-dimer. In the absence of clinical signs of sepsis, FIRS was diagnosed. The neonate was treated with corticosteroids, heparin infusion and recombinant tissue plasminogen activator, and required surgical embolectomy followed by right limb amputation. By Day 31 of life, inflammatory markers showed serial return to normal and the neonate was discharged on oral steroids and aspirin. Intrauterine SARS-CoV-2 infection may trigger a systemic inflammatory response in some fetuses which is similar to post-COVID-19 multisystem inflammatory syndrome in children (MIS-C). Development of lower limb gangrene is a unique COVID-19-related neonatal complication and is attributed to thrombo-inflammation.ABBREVIATIONSCRP: C-reactive protein; FIRS: fetal inflammatory response syndrome; MIS-C: multisystem inflammatory syndrome in children; NT-proBNP: N-terminal pro-brain natriuretic peptide; RT-PCR: real-time polymerase chain reaction.

Aortic arch thrombosis complicated by an embolic stroke in a patient with COVID-19: A case report.

INTRODUCTION: Aortic thrombosis is an uncommon condition with serious embolic complications. COVID-19 is currently recognized to be associated with both venous and arterial thrombosis. However, only a limited number of COVID-19 cases associated with aortic thrombosis have been reported in the literature since the beginning of the pandemic. CASE PRESENTATION: A 66-year-old lady was admitted to our hospital with acute ischemic stroke. Floating aortic arch thrombus was detected incidentally on CT imaging. Interestingly, the patient reported a history of fever and cough and was found to have COVID-19 pneumonia based on nasopharyngeal polymerase chain reaction (PCR) and imaging. The patient received three months of anticoagulant therapy, and repeated imaging study did not reveal any aortic thrombus. CLINICAL DISCUSSION: COVID-19 related aortic thrombosis has been reported chiefly in severe cases. The SARS-CoV-2 can directly infect the endothelium of the vessels, which might explain the occurrence of arterial thrombosis in milder COVID-19 cases with the absence of the hyperinflammatory state. The management guideline for aortic thrombosis is scarce and based only on case reports and series. CONCLUSION: Aortic thrombosis is a devastating condition that can be easily missed without clinical suspicion. Our patient developed acute ischemic stroke, most likely embolic originating from the aortic thrombus. The clinician should consider this condition in any COVID-19 patient presenting with thromboembolic events, such as stroke or acute limb ischemia. Further study is required to explain the pathophysiology of arterial/venous thrombosis in mild-moderate COVID-19 cases.