Sequence of actions for visualization of soft tissue hemorrhages/hematomas in elderly patients infected with SARS-CoV-2.

Aim. To determine ultrasound, computed tomography and angiographic image characteristics for soft tissue hemorrhages/hematomas, the sequence of using imaging methods in patients infected with SARS-CoV-2, to study the morphology of changes in soft tissues, to determine the essence of the concept and to develop treatment tactics for this complication of COVID-19. Material and methods. During 4 months of treatment of elderly patients (+60) infected with SARS-CoV-2, 40 patients were identified with soft tissue hemorrhages/hematomas, of which 26 (65%) patients with large hematomas (>10 cm in size and > 1000 ml in volume). The analysis of clinical and laboratory parameters, methods of instrumental diagnostics (ultrasound - 26 patients, CT - 10 patients, angiography - 9 patients, punctures - 6 patients) was carried out;autopsy material was studied in 11 cases. Results. Image characteristics of hemorrhages/hematomas of soft tissue density were obtained using modern instrumental methods, and the sequence of application of visualization methods was determined. A tactic for managing a patient with stopped and ongoing bleeding has been developed. The morphological substrate of hemorrhagic complications in a new viral infection was studied. All patients were treated with conservative and minimally invasive procedures (embolization, puncture with pressure bandage). 15 patients (57.7%) recovered, 11 patients (42.3%) died from the progression of COVID-19 complications. Conclusion. Comprehensive clinical and laboratory sequential instrumental diagnosis of soft tissue hemorrhages in COVID-19. Treatment should be conservative and significantly invasive. The use of the term "soft tissue hematoma" in SARS-CoV-2 infected patients is not a natural quality of the normal pathological process and should not be observed from our point of view.Copyright © 2022 Rostovskii Gosudarstvennyi Meditsinskii Universitet. All rights reserved.

COVID-19-Related Spontaneous Aortic Arch Thrombus With Delayed Embolization.

Presentation of a 62-year-old man with baseline chronic obstructive pulmonary disease admitted to the hospital with dyspnea and newly diagnosed COVID-19 infection. CT scan of the chest was obtained to rule out pulmonary embolism. This revealed a mural thrombus of the inner curvature of the aortic arch with a floating component. Therapeutic full dose anticoagulation was initiated in combination with close clinical observation and treatment for modest hypoxia. He did well for 1 month and then returned with ischemic rest pain of the right foot. Angiography revealed thrombosis of all 3 tibial arteries in the right leg. Percutaneous mechanical thrombectomy with tissue plasminogen activator injection and angioplasty was performed with success in 1 tibial artery to achieve in line flow to the foot. After continued anticoagulation, the remainder of the tibial arteries autolysed and the aortic thrombus was noted to be resolved 4 months later. A brief pathophysiology discussion is included.

Pulmonary sarcoidosis

The lung is the most common organ affected by sarcoidosis. Multiple tools are available to assist clinicians in assessing lung disease activity and in excluding alternative causes of respiratory symptoms. Improving outcomes in pulmonary sarcoidosis should focus on preventing disease progression and disability, and preserving quality of life, in addition to timely identification and management of complications like fibrotic pulmonary sarcoidosis. While steroids continue to be first-line therapy, other therapies with fewer long-term side-effects are available and should be considered in certain circumstances. Knowledge of common clinical features of pulmonary sarcoidosis and specific pulmonary sarcoidosis phenotypes is important for identifying patients who are more likely to benefit from treatment.Copyright © ERS 2022.

Endovascular Treatment of Pulmonary Artery Pseudoaneurysms Post-COVID-19 Pneumonitis

Pulmonary artery pseudoaneurysms (PAPs) are uncommon entities consisting of contained rupture of the pulmonary artery and are a potentially fatal cause of hemoptysis. We describe two index cases of left lower lobe PAPs and arterial ectasia post-COVID-19 pneumonitis and their endovascular treatment with Amplatzer vascular plug, coils, and glue.Copyright © 2022. Indian Society of Vascular and Interventional Radiology. All rights reserved.

HEMORRHAGIC SHOCK SECONDARY TO LUMBAR ARTERY RUPTURE

SESSION TITLE: Critical Cardiovascular Disorders SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Hemorrhagic shock is a life-threatening condition in which severe blood loss results in cellular and tissue hypoxia. The bleeding can be external or internal. Internal bleeding to one of the body cavities;retroperitoneum, as well as the proximal thigh. Diagnosing nontraumatic bleeding can be challenging and needs a high index of clinical suspension. Here we present a case of hemorrhagic shock secondary to spontaneous lumbar artery rupture causing retroperitoneal bleeding. CASE PRESENTATION: Here we present a 73-year-old male patient with a history of renal cell carcinoma metastatic to the lungs and stage 3 chronic kidney disease (CKD), who presented with confusion, one day after he tested positive for covid after he had a fever and flu-like symptoms for about 4 days. On admission, he was hemodynamically stable and saturating well on ambient air. Head computed tomography (CT) scan and Chest radiograph were negative for acute insults. On the day after admission, his mental status deteriorated, developed acute hypoxic respiratory failure requiring 4 liters of oxygen per minute, tachycardia, and skin mottling over his hands and feet. Labs revealed elevated serum D-dimer. He was started on full-dose anticoagulation with Enoxaparin, and a CT angiogram of the chest was done and revealed new multifocal infiltrates consistent with COVID pneumonia but no pulmonary embolism. He was treated started on IV antibiotics, in addition to Remdesivir and hydrocortisone were started. On the fourth day of admission, he collapsed suddenly and became profoundly hypotensive. Repeat labs revealed a significant hemoglobin drop from 12 to 7.5 g/dl, and creatinine went up to 2.8 mg/dl. An emergent CT of the abdomen revealed an acute retroperitoneal hematoma with active extravasation. After adequate resuscitation and vasopressor support, an aortic angiogram was done showing lumbar artery bleeding requiring embolization, which was done, however, he remained hypotensive and went into cardiac arrest with failed resuscitation. DISCUSSION: Spontaneous lumbar artery rupture is a rare entity (1). Most of the reported cases had chronic kidney disease and were receiving anticoagulation (2,3). It can result in retroperitoneal hematoma, which can present with abdominal pain, hemodynamic instability, and nonspecific symptoms. Abdomen pelvis CT scan with contrast is needed to evaluate for the presence of retroperitoneal hematoma. In addition to resuscitation with fluid and blood products, urgent angiography is needed to confirm the bleeding site and to control it (e.g. embolization). CONCLUSIONS: Spontaneous Lumbar artery rupture should be considered in patients with chronic kidney disease and/or on anticoagulation who are in shock without obvious cause. It's a life threatening condition that needs immediate recognition. Reference #1: Kim JY, Lee SA, Hwang JJ, Park JB, Park SW, Kim YH, et al. Spontaneous lumbar artery rupture and massive retroperitoneal hematoma, successfully treated with arteriographic embolization. Pak J Med Sci. 2019;35(2):569-574. doi: https://doi.org/10.12669/pjms.35.2.639 (Literature review) Reference #2: Hwang NK, Rhee H, Kim IY, et al. Three cases of spontaneous lumbar artery rupture in hemodialysis patients. Hemodial Int 2017;21: E18-21 Reference #3: Sun, PL., Lee, YC. & Chiu, KC. Retroperitoneal hemorrhage caused by enoxaparin-induced spontaneous lumbar artery bleeding and treated by transcatheter arterial embolization: a case report. Cases Journal 2, 9375 (2009). https://doi.org/10.1186/1757-1626-2-9375 DISCLOSURES: No relevant relationships by Mohamad Al-Momani No relevant relationships by Rami Dalbah No relevant relationships by Mohammad Darweesh No relevant relationships by Ratib Mahfouz No relevant relationships by nizar obeidat No relevant relationships by Ahmad Othman

TULAREMIA PRESENTING AS LARGE GI ULCERATION AND HEMORRHAGE

SESSION TITLE: Critical Care Infections SESSION TYPE: Case Reports PRESENTED ON: 10/19/2022 09:15 am - 10:15 am INTRODUCTION: Francisella tularensis is a zoonotic disease by an aerobic, gram negative coccobacillus. It is transmitted by exposure to infected animal or vectors in individuals who landscape or camp. Common symptoms are fever, chills, anorexia, and headache. Abdominal tularemia can present with abdominal pain, emesis, diarrhea, and rarely intestinal ulceration and hemorrhage. It is treated with aminoglycosides, fluoroquinolones and tetracycline. CASE PRESENTATION: 38-year-old male presented with fever, cough, anorexia, and black stool for 5 days. Patient worked as a landscaper. He has no pets, travel history or sick contacts. He does not take any medications at home. Physical exam was significant for sinus tachycardia and rhonchi of right upper lobe. Significant labs include WBC of 9.8 with 41% bands, hemoglobin 15.5, sodium 125, procalcitonin 27.3, and lactic acid 1.8. COVID-19, MRSA, Legionella and Pneumococcal urine antigen were negative. CTA chest revealed mass-like opacity in right upper lobe with multiple bilateral pulmonary nodules. Lower respiratory culture showed Candida albicans. Patient was empirically started on ceftriaxone and azithromycin. He was transferred to intensive care for worsening respiratory status and was placed on non-invasive ventilation on hospital day 1. Antibiotics were broadened to ceftaroline and levofloxacin due to suspicion of tularemia. Amphotericin B was added. Labs for Histoplasma, Blastomyces, TB, Leptospira, and HIV were negative. Patient then suffered a cardiac arrest on hospital day 2 after having large brown secretions pouring from his mouth. Cardiopulmonary resuscitation was initiated and patient was intubated and started on vasopressors with return of spontaneous circulation. Massive blood transfusion protocol was initiated. Emergent bedside upper endoscopy showed large blood clot adherent to duodenal ulcer. Interventional radiology planned on performing gastric duodenal artery embolization. However, patient suffered two more cardiac arrest with resuscitation efforts terminated per family request. Karius Digital Culture later was positive for Francisella tularensis. Autopsy revealed diffuse alveolar hemorrhage, hilar lymphadenopathy, and perforated duodenal ulceration with large adherent clot. DISCUSSION: Gastrointestinal tularemia is rare and usually from drinking contaminated water or oral inoculation of bacteria. Intestinal tract involvement can present with mesenteric lymphadenopathy and ulcerative lesions resulting in gastrointestinal bleeding with case fatality rate of 50%. Even though this is noted in the literature, to our knowledge no case reports have been published. CONCLUSIONS: Careful history taking and early identification of risk factors are important when severe tularemia infection is suspected such as in individuals with extensive outdoor activities. Treatment should be empirically initiated in high risk patients. Reference #1: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4585636/ Reference #2: https://casereports.bmj.com/content/2017/bcr-2017-22125. Reference #3: Altman GB, Wachs JE. Tularemia: A pathogen in nature and a biological weapon. Aaohn Journal. 2002 Aug;50(8):373-9. DISCLOSURES: No relevant relationships by Maria Haider Baig

MIDDLE MENINGEAL ARTERY EMBOLIZATION AS A SAME-DAY DISCHARGE PROCEDURE

Introduction Middle meningeal artery embolization (MMAE) is a fundamental piece in the management of Chronic Subdural Hematoma (cSDH) that prevents recurrence and can serve as primary treatment for nonoperative candidates. MMAE offers time-effectiveness, since it may be performed in less than one hour under minimal sedation. As the COVID-19 pandemic makes inpatient beds scarce, MMAE could potentially become a same-day procedure which poses a potential economic benefit for both patients and health institutions alike. We reviewed MMAEs performed at our institution and measured the complication rates in an effort to determine if hospital admission after the procedure is necessary. Methods A retrospective analysis of patients who underwent MMAE for cSDH at the University of California, San Diego was performed. Data collected included post-procedural complications such as focal neurologic deficit, cognitive decline, and groin access-point hemorrhage identified within the first 4 hours, 24 hours, and delayed manner respectively. Success of treatment was defined as patient stability and return to baseline following the post-procedure assessment protocol performed routinely at our institution. We further characterized patients with the Charlson Comorbidity Index (CCI) to identify higher risk populations that would require increased observation. The CCI was also used to determine a cut-off point for same-day discharge eligibility. Results We analyzed data from 95 patients that had 143 subdural hematomas treated at our institution. Of the 95 patients, 93 patients (98%) had no complications following our institution's standardized assessments after MMAE or at discharge the following day. Average SDH size was 12.9mm. Twenty-one patients underwent surgical drainage after MMAE. Following MMAE, two patients presented complications;one patient, an 83-year-old female, developed transient headache and blurry vision one day after MMAE and was discharged uneventfully;this patient had a CCI of 4 points. The other patient was a 77-year-old male with metastatic prostate carcinoma and had an SDH volume expansion one day after the procedure which required operative intervention with burr-hole craniotomy and drainage;this patient had a CCI of 9 points (0% estimated 10-year survival). The remaining 93 patients suffered no complications after MMAE. Conclusion Time-effectiveness and low complication rates make MMAE an ideal same-day procedure for patients with cSDH and a low CCI score. The grand majority of patients had no complications following MMAE, suggesting a large patient population that may benefit from the same-day procedure aspect of intervention. Although some patients underwent planned surgical drainage, the embolization component of management was uneventful. Our analysis provides evidence that MMAE could develop into an ambulatory procedure in patients with cSDH and a low comorbidity profile;this could have economic benefits for both the patients requiring and the institutions offering the procedure. Further prospective studies are needed to strengthen these findings.

Rasmussen's Aneurysm - A fatal and rare complication in post COVID-19 pneumonia

Background: Post COVID -19 infection has wide range of presentation, cavitation and fungal infections were very common in these patients especially when they are immune compromised. This is a case study of a post covid patient with cavitary consolidation and Rasmussen's aneurysm secondary to invasive aspergillus infection. Case Study: A 62 year old gentleman, hypertensive, diabetic and survivor of severe COVID-19 infection presented with low grade fever, breathlessness and cough with expectoration. The CT scan showed bilateral cavitary consolidation . Sputum examination showed aspergillus growth and MTB negative. Serum galactomannan was positive. While getting treated with antifungal therapy for invasive aspergillus infection, he had one episode of massive haemoptysis. CT angiography showed Rasmussen aneurysm and planned for bronchial artery embolization. But the patient was not willing for any urgent intervention and got discharged on request after stabilisation, warning signs were explained. After 5 days patient had massive haemoptysis followed by circulatory collapse. Patient could not be saved even after resuscitation measures and emergency intubation. Discussion: Rasmussen's aneurysm is a pseudo-aneurysmal dilatation of a branch of pulmonary artery secondary to chronic inflammation in a contiguous cavity. The reported incidence of such pathology is around 5% in cavitary lesions. It may ruptures into the cavity, producing massive haemoptysis. Conclusion: Rasmussen aneurysm itself is a very dangerous entity irrespective of its etiology. Early interventions to prevent the fatal haemoptysis is the management strategy as conservative treatment may not give us enough time to act at the time of emergency.

Vascular Thromboembolism is a Grave Complication of COVID-19

There is ample evidence that the coronavirus can cause fatal blood clots. Angiotensin-converting enzyme 2 (ACE2) receptors act as a gateway for the coronavirus to enter the body and facilitate infection. ACE2 receptors are scientifically linked to disease severity in smokers because nicotine is thought to affect ACE2 expression in different ways. Patients admitted with severe COVID-19 infection with high levels of factor V Leiden are prone to serious damage from blood clots such as deep vein thrombosis or pulmonary embolism. Damage to the vascular endothelium is a complication that can be caused by the coronavirus. It can cause vascular clots, in the formation of which factors such as age, sex, blood type, and underlying diseases are effective. Thrombotic events, especially venous thrombosis, following COVID-19 infection have already been described;nonetheless, data are scarce on arterial thrombosis. Herein we report 4 cases of COVID-19 infection complicated by arterial thrombosis. (Iranian Heart Journal 2022;23(1): 223-227).

Middle meningeal artery (MMA) embolization for chronic subdural haematoma: A prospective UK study

Objectives: MMA embolization has emerged in recent years as a safe and minimally invasive treatment for a chronic subdural haematoma. We report the first UK series of endovascular treatments of chronic subdural haematomas. Design: Prospective case series. Subjects: All adult patients referred with minimal midline shift (≤8 mm) and GCS ≥14/15 were considered. Patients had to be mobile with a standard origin of Middle Meningeal and Ophthalmic arteries. Patients with GCS ≤13 or profound weakness (MRC grade ≤3) were treated with Burr hole drainage and placement of subdural drains. Methods: Patients were recruited over a 7-month period from 25/10/2020 to 25/05/2021 through our electronic referral system. Patients' demographics, pre-morbid modified Rankin Score (mRS), symptoms, anticoagulation, and co-morbidities were prospectively collected. Suitability for endovascular treatment was discussed with the Neurovascular radiologist and neurosurgeon. SQUID-12 embolic material was used for all MMA embolizations which were performed under General Anaesthetic. Baseline CT/MRI characteristics were collected. Further imaging was obtained at 7, 21, 90, and 180 days. Clinical assessment and mRS were completed at three months. Results: Ten patients underwent endovascular embolization of MMA in the study period. Of these eight were male, the median age was 79 years. The median length of stay was 3 days. Follow-up CT at 3 weeks, obtained for 6/10 patients, has demonstrated significant reduction in both midline shift (μ = 3.3 mm, p = 0.0019) and maximum thickness of haematoma (μ = 5.8 mm, p = 0.0055). At the time of submission, five patients had reached the three months' follow-up period, of which, three had a complete radiological resolution, with a further patient observed to have >50% improvement in CT parameters. We report one mortality due to COVID-19. Conclusions: For select patients, MMA embolization is a safe, minimally invasive, and effective treatment for a chronic subdural haematoma. As we gain more experience, the procedure could be performed under local anaesthetic.

CoViD-19 and complications: pectoral hematoma, a rare condition

Background: Patients with CoViD-19 pneumonia have hyperactive coagulation status and one of the main causes of death is pulmonary embolism. They also suffer from hypoxia, so they need respiratory support and prone positioning. Description of the case: A 59-year old woman (weight 100 Kg, BMI 32) came to our hospital reporting fever and dyspnea. Chest X-ray: extensive parenchymal thickenings in the subpleural regions of both lungs. Analysis: hemoglobin 14.7 g/dl, creatinine 1.18 mg/dl, D-Dimer >10000 ng/dl, pO2/FiO2 124. Treatment: antibiotics, hydroxychloroquine, tocilizumab, high flow oxygen alternating with NIV, dexamethasone, enoxaparin 8000 U bid and alternating supine and prone position. Eighteen days after admission we noticed a swelling in her breast. A thoracic CT scan showed a leveled hematoma (16x10cm) below the left pectoralis major muscle, an arterial spread from the lateral thoracic artery, a thromboembolic image in a subsegmentary branch of the pulmonary artery and extended bilateral ground glass. The patient underwent blood transfusions for acute anemia (hemoglobin 6.9 g/dl) and multiple arterial embolizations. Conclusions:We hypothesized that the pro-inflammatory endovascular condition, in a severe CoViD-19, and the anticoagulant treatment have determined fragility of the vascular wall. In addition, the continuous changes of posture have probably led to a repeated traumatism and rupture of blood vessels. Therefore in obese women, whose lateral thoracic artery is large and emits mammary branches, pronosupination should be personalized taking into account enoxaparin dosage.

A case of granulomatosis with polyangiitis complicated by COVID-19: Challenges in diagnosis and management

Case report-IntroductionGranulomatosis with Polyangiitis (GPA) is a rare small-to medium-vessel vasculitis associated with anti-neutrophil cytoplasmic autoantibody (ANCA). Its multi-systemic features include pulmonary, ear, nose, and throat (ENT), renal, and neurological manifestations. Its incidence is estimated to be 10.2 cases per million population. It is challenging to diagnose when its symptoms are treated in isolation from one another. This case highlights the difficulty in diagnosing GPA in a patient with respiratory symptoms during the Coronavirus Disease 2019 (COVID-19) pandemic and describes the challenges of managing it in the context of a subsequent COVID-19 infection as the mainstay of treatment remains immunosuppression.Case report-Case descriptionA 78-year-old female non-smoker with a history of leg ulcers developed a 3-month history of cough and haemoptysis and was treated in primary care for suspected sinus and chest infections. She then presented to Accident and Emergency twice for the same symptoms and was discharged after having her antibiotics changed.2 weeks later, she presented for the third time with cough, ongoing haemoptysis, conjunctivitis in the right eye, pain over the right side of her head, and discharge from her right ear. She was admitted as she was pyrexical, tachycardic and her CRP was 60. COVID-19 swabs were negative. ENT team recommended IV ceftriaxone and metronidazole for suspected orbital cellulitis. Blood cultures remained negative. CT sinuses with contrast showed right sided thrombosis of transverse sinus and bilateral mastoid effusion of the middle ear. Following neurology review, she was anticoagulated with dalteparin. A day later, she was transferred to the Respiratory ward and dropped her Haemoglobin level to 70. Her chest radiograph showed diffuse alveolar haemorrhage and CT images showed widespread bilateral peri-hilar consolidation.A rheumatology opinion was sought and vasculitic screen showed ANCA 268, and PR3 >177. Her urinary protein/creatinine ratio was elevated at 90. Rheumatology team confirmed multi-systemic GPA and recommended starting oral Prednisolone 60 mg daily. After the renal team was consulted, she was moved to a side-room and started on IV Methylprednisolone (pulsed with three doses), along with cyclophosphamide and rituximab. Dalteparin was discontinued.2 days later, she desaturated, and became pyrexical. Repeat COVID-19 swabs were positive.Three Consultants agreed that Plasma Exchange and Non-Invasive Ventilation (NIV) would be inappropriate. A Do Not Attempt Resuscitation form was signed, and prognosis was discussed with the patient and her 78-year-old husband who requested to visit. Patient deteriorated and unfortunately died 6 days later.Case report-DiscussionThis case is interesting because it highlights the diagnostic challenge of GPA. Retrospectively, it may be noted that doctors persisted in treating suspected infection although the patient continued to deteriorate. However, a diagnosis should be re-considered if the patient does not respond to treatment and it is important to consider vasculitis as a cause of haemoptysis.Anticoagulation was started since the benefits were considered to outweigh the risks as her haemoptysis was of small volume. The patient soon developed pulmonary haemorrhage, so the risks of anticoagulation should not be underestimated in vasculitis.The Rheumatology team's cautious approach to immunosuppression was in stark contrast to the renal team's aggressive approach. The Renal team believed that concerns about protecting the patient from COVID-19 when she was negative from this infection should not take precedence over appropriate immunosuppression from a potentially fatal vasculitis.The patient was admitted at the start of the COVID-19 pandemic and was negative for COVID-19 on admission. She was nursed in a bay on the Respiratory ward where she later became COVID-19 positive. This raises questions about whether the earlier test was a false negative result or whether her infection was hospital-acquired. Infection cont ol guidelines were changing rapidly at the start of the COVID-19 pandemic.The decision to avoid plasma exchange was based on the findings of the PEXIVAS trial. NIV was avoided as it required a full-face mask to minimize particle dispersion but would pose an asphyxiation risk as patient was coughing up blood.Finally, the team learnt to be flexible in these extraordinary circumstances when dealing with the end-of-life decisions of the COVID-19 positive patient. Although her husband was a vulnerable person because of his age, he was given the opportunity to visit while wearing Personal Protective Equipment and agreed to self-isolate for two weeks.Case report-Key learning pointsThis case helped me appreciate the complexity of deciding to immunosuppress an already severely ill patient in the context of the COVID-19 pandemic. I recognised that the patient had a poor prognosis with or without immunosuppression and our role as healthcare professionals was to give her the best chance of recovery. The conference will allow me to interact with other colleagues and discuss what they would do in this situation as our Rheumatology and Renal teams had different approaches.After further reading on false negative results, we found that Johns Hopkins researchers found that testing people for SARS-CoV2 too early in the course of infection is likely to result in a false negative test even though they may eventually test positive for the virus.I have also learnt about the PEXIVAS trial which found that the addition of plasma exchange to standard therapy does not reduce the risk for all-cause mortality among patients with severe ANCA-associated vasculitis. Moreover, a reduced-dose regimen of glucocorticoids is non-inferior to a standard-dose protocol, while reducing the risk for serious infections.Diffuse alveolar haemorrhage (DAH) is not treatable with arterial embolization or bronchoscopic methods due to the diffuse nature of the bleeding. Extracorporeal membrane oxygenation (ECMO) has been used to support patients with DAH but the use of ECMO is controversial due to the need for anticoagulation.The conference will help me deepen my understanding of epidemic rheumatology which will be useful for my clinical practice going forward, especially if there is a second wave of the COVID-19 pandemic. I am keen to use this event to engage with other clinicians on immunosuppression in the context of infection so that I may confidently manage similarly complex cases in the future.

Management of Spontaneous Bleeding in COVID-19 Inpatients: Is Embolization Always Needed?

BACKGROUND: critically ill patients with SARS-CoV-2 infection present a hypercoagulable condition. Anticoagulant therapy is currently recommended to reduce thrombotic risk, leading to potentially severe complications like spontaneous bleeding (SB). Percutaneous transcatheter arterial embolization (PTAE) can be life-saving in critical patients, in addition to medical therapy. We report a major COVID-19 Italian Research Hospital experience during the pandemic, with particular focus on indications and technique of embolization. METHODS: We retrospectively included all subjects with SB and with a microbiologically confirmed SARS-CoV-2 infection, over one year of pandemic, selecting two different groups: (a) patients treated with PTAE and medical therapy; (b) patients treated only with medical therapy. Computed tomography (CT) scan findings, clinical conditions, and biological findings were collected. RESULTS: 21/1075 patients presented soft tissue SB with an incidence of 1.95%. 10/21 patients were treated with PTAE and medical therapy with a 30-days survival of 70%. Arterial blush, contrast late enhancement, and dimensions at CT scan were found discriminating for the embolization (p < 0.05). CONCLUSIONS: PTAE is an important tool in severely ill, bleeding COVID-19 patients. The decision for PTAE of COVID-19 patients must be carefully weighted with particular attention paid to the clinical and biological condition, hematoma location and volume.

Life-Threatening Psoas Hematoma due to Retroperitoneal Hemorrhage in a COVID-19 Patient on Enoxaparin Treated With Arterial Embolization: A Case Report.

Respiratory failure is presumptively caused by microvascular thrombosis in some patients with coronavirus disease 2019 (COVID-19) requiring therapeutic anticoagulation. Anticoagulation treatment may cause life-threatening bleeding complications such as retroperitoneal hemorrhage. To the best of our knowledge, we report first case of a COVID-19 patient treated with therapeutic anticoagulation resulting in psoas hematoma due to lumbar artery bleeding. A 69-year-old patient presented with fever, malaise and progressive shortness of breath to our hospital. He was diagnosed with COVID-19 by RT-PCR. Due to an abnormal coagulation profile, the patient was started on enoxaparin. Over the course of hospitalization, the patient was found to have hypotension with worsening hemoglobin levels. Computed tomography scan of the abdomen and pelvis revealed a large psoas hematoma. Arteriogram revealed lumbar artery bleeding which was treated with embolization. Anticoagulation therapy, while indicated in COVID-19 patients, has its own challenges and guidelines describing dosages and indications in this disease are lacking. Rare bleeding complications such as psoas hematoma should be kept in mind in patients who become hemodynamically unstable, warranting prompt imaging for diagnosis and treatment with arterial embolization, thus eliminating need of surgical intervention.