An audit of paroxysmal nocturnal haemoglobinuria (PNH) requesting at University Hospitals of North Midlands

Early identification of PNH, a rare life-threatening disease is essential to ensure appropriate management via the UK PNH service. Since testing for PNH is expensive (75.97 per test), we set out to assess the suitability of PNH requests against guidelines with the aim to feedback to colleagues and reduce unnecessary testing. To determine whether PNH requests at UHNM were in line with criteria in British Society for Haematology (BSH) guidelines. All patients over 18 years of age who had PNH testing for the first time and those who had repeat testing for monitoring between 01/04/2019 and 31/03/2020 were included. Patients were selected from electronic records of PNH sample receipt to laboratories. Hospital records were reviewed for clinical details and investigation Results. 82 requests including 79 individual patients were audited. 57% were male and 43% were female. Median age was 56 years. 97.6% of PNH tests were requested by a haematologist whilst only 2.5% requests were done by non-haematology clinicians. 52.4% requests were in keeping with BSH recommendations, whilst 47.6% tests did not meet criteria for testing. All patients tested outside of guideline recommendations were negative. Of the reasonable requests, only 23.3% (10) were positive. Of the PNH positive patients, 8 patients were known to have a PNH clone with aplastic anaemia;one patient had a hypoplastic bone marrow and a known PNH clone whilst only one patient with cytopenia had a new positivity for PNH. The frequency monitoring for aplastic anaemia and a PNH clone was 100% concordant with BSH recommendations. With appropriate testing, only one new patient was identified. Our audit has limitations. We have not been able to assess whether any patients outside of those monitored for PNH in aplastic anaemia have been overlooked for testing. Also, the time period includes the COVID-19 pandemic so our findings may not reflect usual practice. New BSH guidelines for thrombophilia testing were published in 2022 and recommend testing for PNH in patients with thrombosis at unusual sites and abnormal haematological parameters and for patients with arterial thrombosis and abnormal blood parameters. This will likely limit excess tests although the sensitivity and specificity of such an approach has not been formally evaluated. In a finite health system, it is our responsibility to rationalise investigations. The cost of a year's testing was 6229.54 and that of inappropriate testing was 2962.83. As a department, we could, therefore, save 2962.83.

Surgical clinical characteristics of acute arterial thrombosis of the extremities in the context of SARS-CoV-2 infection

Objective: To determine the clinical-surgical features of critical limb ischaemia (CLI) within the context of infection by SARS-CoV-2. Method(s): Cross-sectional, retrospective, observational, descriptive study, with clinical data obtained from printed and electronic records of patients with CLI treated by the Angiology and Vascular Surgery Service of the General Hospital of Mexico in the period between January 2020 and July 2021. Result(s): We evaluated the data of 33 patients with critical limb ischaemia of which 15 were positive for SARS-CoV-2 in the period from January 2020 to July 2021, females were the most affected representing the 53.3% of the total, patients under 60 years old accounted for 26.67%. Twenty-six percent of the patients presented critical limb ischaemia without having previous comorbidities, 60% of these presented with an advanced state of the disease and a delay in specialised medical care of more than 6 hours after the onset of symptoms, which warranted a major amputation in 37% of cases, the lower extremities represented 90% of the affected anatomical regions. Conclusion(s): the outcomes in our study show that the incidence of critical limb ischaemia during the SARS-CoV2 pandemic period occurred in an atypical way in a segment of young patients and without known event-generating comorbidities. Thromboembolic events, probably associated with the hypercoagulable state generated by this infection, also evolved rapidly and aggressively from the onset of symptoms despite prompt treatment.Copyright © 2022 Sociedad Medica del Hospital General de Mexico. Published by Permanyer.

A case report overlapped vaccine and COVID-19 in disseminated atherosclerosis.

Coronavirus disease 2019 (COVID-19) has become a part of our lives now and we have no more effective way of coping than a vaccine. COVID-19 is a disease that causes severe thrombosis outside the respiratory tract. Vaccines also protect us in this respect, but in some rare cases, thrombosis has been found to develop after vaccination (much less frequently than COVID-19). What was interesting in our case was that it showed how a disaster could happen under three factors that predispose to thrombosis. A 65-year-old female patient with disseminated atherosclerosis was admitted to the intensive care unit with complaints of dyspnea and dysphasia. In the evening of the day, the patient had the vaccination 2 weeks ago, she had active COVID-19. On examination, lower extremity pulses could not be detected. The patient's imaging and blood tests were performed. Multiple complications such as embolic stroke, venous and arterial thrombosis, pulmonary embolism, and pericarditis were observed in the patient. This case may give consideration to anticoagulant therapy studies. We give effective anticoagulant therapy in the presence of COVID-19 in patients at risk of thrombosis. Can anticoagulant therapy be considered after vaccination in patients at risk of thrombosis such as disseminated atherosclerosis?

Coagulopathy: A Vicious Indicator of COVID-19

COVID-19 is routinely associated with coagulopathy and complications associated with thrombosis. However, the difference between the coagulopathy, which is associated with COVID-19 and the coagulopathy, which is due to different causes, is that the "COVID-19 associated coagulopathy" shows raised levels of D-Dimer and that of fibrinogen. However, it shows quite some abnormalities in the levels of prothrombin time and also in the platelet count. "Venous thromboembolism" and arterial thrombosis is frequently seen in COVID-19 associated coagulopathy as opposed to "disseminated intravascular coagulopathy". Patients suffering from COVID-19 have many have multiple factors in common for thromboembolism which is associated with "Adult respiratory distress syndrome" from different etiologies like generalized inflammation and being unambulatory. "Cytokine storm" is the hallmark of COVID-19 associated coagulopathy which is distinguished by high levels of IL-6,1, tumour necrosis factor and other cytokines. The clinical features of COVID-19 associated coagulopathy overlap that of some syndromes like antiphos-pholipid syndrome and thrombotic microangiopathy. Studies have shown that patients diagnosed with disseminated intravascular coagulation have a poor prognosis compared to the one's that don't get diagnosed with DIC. The advancement of the condition from coagulopathy in the vasculature of the lungs to DIC in patients who have tested positive for COVID-19 shows that the patient's dysfunction associated with coagulation has evolved from local to generalized state. Investigating the coagulopathies will help in understanding the mechanism of COVID-19 associated coagulopathy.Copyright © International Journal of Research in Pharmaceutical Sciences.

Long-term effects of coronavirus disease 2019 on the cardiovascular system: The CV COVID-19 registry

Background: Patients with COVID-19 have an increased risk of cardiovascular adverse events during the acute phase. However, the long-term cardiovascular outcomes are unknown. Objective(s): We aimed to determine the long-term effects of COVID-19 in the cardiovascular system. Method(s): This is a multicenter, observational, retrospective registry conducted at 17 centers in Spain and Italy. Consecutive patients older than 18 years who underwent a real-time reverse transcriptase-polymerase chain reaction (RT-PCR) for SARS-CoV2 in the participating institutions were included. Patients were classified into two groups, according to the results of the RT-PCR: COVID-19 positive or negative. The primary outcome was cardiovascular (CV) death at 1-year. The secondary outcomes included acute myocardial infarction, stroke, heart failure hospitalization, pulmonary embolism, and serious cardiac arrhythmias at 1-year. Outcomes were compared between the two groups. An independent clinical event committee adjudicated events. Result(s): A total of 4427 patients were included, 3578 (80.8%) patients with COVID-19 and 849 (19.2%) without COVID-19. COVID-19 patients were older, had a higher rate of classical cardiovascular risk factors, except for active smoking, and had fewer comorbidities. At a median time of 13.5 (IQR 11.8-15.8) months, after an adjustment by baseline characteristics, there was no difference in CV death (1.4% vs. 1.1%;HR 1.03 [0.49-2.18];p=0.941) between patients with COVID-19 and without. However, COVID- 19 patients experienced higher rate of venous thromboembolism (VTE) (3.9% vs. 0.6%, HR 6.11 [2.46-15.16];p=0.001), major bleeding (2.9% vs. 0.5%, HR 5.38 [1.95-14.84];p=0.001), and serious cardiac arrhythmias (2.6% vs. 0.9%, HR 2.25 [1.07-4.73];p=0.033). During follow-up, between discharge and end of follow-up, COVID-19 patients did not experience a higher risk of adverse cardiovascular outcomes (composite of CV death, any MI, ischemic stroke, systemic arterial thrombosis, VTE, heart failure hospitalization, or any serious arrhythmia) compared to patients without (HR 0.80;[0.53-1.21];p=0.298). Conclusion(s): At 1-year follow-up, COVID-19 was not associated with an increased risk of cardiovascular death but with a higher risk of VTE events, major bleeding, and serious cardiac arrhythmias. COVID-19 was not associated with a higher risk of adverse cardiovascular events during follow-up.

Multivessel Epicardial Coronary Artery Thrombosis after Heart Transplantation

Introduction: Although cardiac allograft vasculopathy (CAV) remains one of the leading causes of graft failure after heart transplantation (HTx), simultaneous thrombosis of multiple epicardial coronary arteries (CA) is an uncommon finding. Case Report: A 43-year-old male patient with non-ischemic dilated cardiomyopathy underwent successful HTx in 2019. The first two years after HTx were uneventful, surveillance endomyocardial biopsies (EMB) did not reveal any rejection episodes, coronary CTA revealed only minimal non-calcified CA plaques. The patient was admitted to hospital due to fever and chest pain in 2021. Immunosuppressive therapy consisted of tacrolimus, mycophenolate-mofetil and methylprednisolone. ECG verified sinus rhythm. Laboratory test revealed elevated hsTroponin T, NT-proBNP and CRP levels. Cytomegalovirus, SARS-CoV-2-virus and hemoculture testing was negative. Several high-titre donor-specific HLA class I and II antibodies (DSAs;including complement-binding DQ7) could have been detected since 2020. Echocardiography confirmed mildly decreased left ventricular systolic function and apical hypokinesis. EMB verified mild cellular and antibody-mediated rejection (ABMR) according to ISHLT grading criteria. Cardiac MRI revealed inferobasal and apical myocardial infarction (MI);thus, an urgent coronary angiography was performed. This confirmed thrombotic occlusions in all three main epicardial CAs and in first diagonal CA. As revascularization was not feasible, antithrombotic therapy with acetylsalicylic acid, clopidogrel and enoxaparin was started for secondary prevention. Tests for immune system disorders, thrombophilia and cancer were negative. Patient suddenly died ten days after admission. Necropsy revealed intimal proliferation in all three main epicardial CAs, endothelitis, thrombosis, chronic pericoronary fat inflammation, fat necrosis, and subacute MI. CA vasculitis owing to persistent high-titre DSAs, chronic ABMR and acute cellular and antibody-mediated rejection led to multivessel CA thrombosis and acute multiple MI. ABMR after HTx may be underdiagnosed with traditional pathological methods. Pathologies affecting coronary vasculature of HTx patients with DSAs, unique manifestations of CAV lesions and occlusive thrombosis of non-stenotic, non-atherosclerotic lesions should be emphasized.Copyright © 2023

Successful Treatment of Subclavian Artery Thrombosis by Catheter-Based Thrombus Aspiration and Thrombolytic Therapy: A Case Report

Clinical Information Patient Initials or Identifier Number: BP4****/22 Relevant Clinical History and Physical Exam: A 55 Y / Female C/C : Pain, numbness, cold sensation & weakness of left upper limb for 2 hours. Risk Factor : Hypertension, diabetes mellitus O/E : Pale, cold and absent of radial, ulnar, brachial pulse of left upper limb. Muscle power 3/5 left side. So2 86%, BP undetectable. Right upper limb were normal. BP 160/90 mm of hg, pules : 112 b/min, RR : 26/min. Body Temperature 37.5 C [Formula presented] [Formula presented] Relevant Test Results Prior to Catheterization: CBC : WBC 7450, HB % 10.8 g/dl, ESR 20mm in 1st hour, Platelets : 262000, SARS Cov2 Antigen : Negative PT 14.3 sec, INR : 1.07 APTT : 32.4 sec. blood group: O positive Serum Creatinine : 1.1 mg/dl Plasma glucose 9.7 mmmol/l HIV Ab : Negative HBs Ag : Negative Anti-HCV : Negative Urine R/E : Normal lipid profile : Cholesterol 280mg/dl Vascular duplex ultrasound of left upper limb : A dilated echogenic thrombus had blocked the left subclaviav artery lumen. Relevant Catheterization Findings: Conventional angiography with the lowest amount of contrast agent through the right femoral artery, revealed that left subclavian artery thrombosis with total occlusion distal to Left internal mammary artery. [Formula presented] [Formula presented] [Formula presented] Interventional Management Procedural Step: A5Fr MPA catheter with side holes was negotiated through a right femoral sheath and was placed in the left subclavian artery. Initially thrombus aspiration was done with Eliminate aspiration catheter (TERUMO) with no success. Then suction was done with the MPA catheter itself with partial removal of thrombus. Then a 5Fr Pigtail catheter was placed inside the thrombus and kept in situ. For residual thrombus 250,000u of Inj. Streptokinase as a thrombolytic drug was given through the Pigtail catheter as bolus over 30 min. The maintenance dose 100,000 u per hour was given over 24 hours through the Pigtail catheter via infusion pump. After 24 hours of thrombolytic therapy, her pain was reduced, the left hand became slightly warm, and distal pulses were feebly palpable. Moreover, the skin colour returned to near normal with improvement of pallor. Bleeding was well controlled at the catheter site. Doppler sounds revealed partial improvement of arterial flow. After evaluation of partial improvement, a low dose 1000 iu per hour of heparin (UFH)was infused intravenously for 24 hours. After 48 hours, repeat angiography via the inserted catheter at the site did not reveal any atherosclerotic plaque and confirm the thrombosis-dissolution. The latter practice demonstrated a good blood flowto the left upper distal limb leaving a little thrombus in the superficial palmer arch. [Formula presented] [Formula presented] [Formula presented] Conclusion(s): Catheter-based thrombus aspiration and thrombolytic therapy is primarily reserved for patients with acute viable limb ischemia. As observed in the presented case, thrombus aspiration and thrombolytic therapy is recommended to be considered as an alternative therapeutic method for patients with arterial thrombosis due to the rapid response, shorter treatment time and lower cost, compared to common and sometimes unsuccessful therapies.Copyright © 2023

EXPERIENCE in the MANAGEMENT of PATIENTS with ARTERIAL and VENOUS THROMBOSIS and COVID-19.

COVID-19 is represented by a large number of different phenotypes, ranging from asymptomatic infection to the development of severe multiple organ dysfunction syndrome. The mechanisms of development of multiple organ dysfunction syndrome are multifactorial, they frequently include hypercoagulable states and Background thrombus formation. Such mechanisms are diagnosed as thrombotic complications that cause blood clots in veins, pulmonary arteries, and coronary arteries. An observational study revealed that the incidence of venous and arterial thrombosis is as high as 31% in patients with COVID-19 pneumonia. However, large studies regarding this topic have not yet been conducted. To compile and analyze our own observations concerning the clinical course of Aim patients with thrombosis in COVID-19. The study included 5 male patients with arterial and venous thrombosis and Methods COVID-19. The experience in the management of 5 patients with COVID-19 and arterial and venous thrombosis was analyzed. All patients exhibited dynamic changes in their blood coagulation tests. The patients with negative COVID-19 test results on Results admission, and changes in the coagulogram indices found on the day of recurrence of thrombosis were of the most interest. All patients received standard treatment and were discharged upon showing improvement and negative COVID-19 test results. Compiling data on the clinical course of patients with COVID-19 and different Conclusion types of thrombosis allowed us to develop treatment strategy for these groups of patients.Copyright © 2021 Russian Academy of Sciences. All right reserved.

Long-term mayor adverse cardiovascular events after COVID-19 infection: A clinical score from a cohort of 2575 patients enrolled in the multicenter international HOPE 2 registry

Background: Long-term consequences of COVID-19 infection are still partly known. According to some studies several patients may experience long term symptoms;however, predictors of long-term mayor adverse cardiovascular events among (MACE) patients with previous COVID-19 infection are . Aim of the study: To derive a simple clinical score for risk prediction of long-term MACE among patients with previous covid-19 infection. Method(s): 2575 consecutive patients were enrolled in a multicenter, international registry (HOPE-2) from February 2020 to April 2021, and followedup at long-term. A risk score was developed using a stepwise multivariable regression analysis. Result(s): Out of 2575 patients enrolled in the HOPE-2 registry, 1481 (58%) were male, with mean age of 60+/-16 years. At long-term follow-up overall rate of MACE was 7.9% (202 of 2545 pts, 3.3% death, 2.4% inflammatory myocardial disease, 1.3% arterial thrombosis, 0.7% venous thrombosis). After multivariable regression analysis, independent predictors of MACE were used to derive a simple prognostic score: The HOPE-2 prognostic score may be calculated by giving: 1/2 point for every 10 years of age, 2 points for previous cardiovascular disease, 1 point for increased troponin serum levels during hospitalization, 2.5 points for heart failure and 3 points for sepsis during hospitalization, -1.5 points for vaccination at followup. Score accuracy at receiver operating characteristic curve analysis was 0.81. Stratification into 3 risk groups (0-2, 3-5, and >5 points) classified into low, intermediate and high risk. The observed MACE rates were 0.5% for low-risk patients, 4% for intermediate-risk patients, and 19.5% for high-risk patients (log-Rank p<0.001, Figure 1). Conclusion(s): The HOPE-2 prognostic score may be useful for long-term risk stratification in patients with previous COVID-19 infection. High-risk patients may require a strict cardiological follow-up. (Figure Presented).

A Comprehensive Review of 275 Kidney Transplants Performed over 3 1/2 Years;a Single Center Experience

Introduction: Access to kidney transplantation has always been a problem in the African countries with many patients having to travel to other medically advanced countries in Asia, Europe and America. This involves unnecessary excessive expenditure and the travails of journey and stay in an unknown foreign land. To ease this situation and to provide affordable Renal transplant services in their home land, we have made an effort to start the transplant services at our medical facility and have successfully carried out about 275 transplants over a period starting from Nov 2018 till September 2022. Method(s): All the Kidney transplants done between the period Nov 2018- September 2022 (275 cases) were included in the analysis. All the transplants were performed at a single center and the data were collected progressively during their Pre transplant evaluation, perioperative course and post op follow up. All the laboratory and radiological tests were done locally at the center except the HLA cross matches and tissue typing, which were outsourced to Transplant immunology labs outside the country. All the patients with positive DSA titres [about 70%], underwent Plasmapheresis and received IVIg before the transplantation. immunological assessment was done by NGS high resolution, for A B C DP DQ DR loci and X match was done by SAB analysis for class 1 and Class II antigens. All the patients underwent laparoscopic donor nephrectomy. All Patients received vaccinations for Hepatitis B, Pneumonia, Infuenza & Covid. Result(s): A series of 275 kidney transplants were performed over a period of 42 months [ Nov 2018- September 2022] at a private hospital successfully. All the cases were live donor kidney transplants with majority of the donors being 1st or 2nd degree relatives or spousal donors. About 70% of the patients had some degree of sensitization in the form of weakly positive B cell X match, or positive for DSAs at CL I, CLII with MFIs > 1000. All high-risk patients received induction with rabbit Thymoglobulin, and IV methyl prednisolone. Around 50 patients received Basiliximab. Of all patients, 4were HBsAg positive, and 6 were HIV positive,& HCV 1 patient. 8 patients required pretransplant Parathyroidectomy for refractory hyperparathyroidism, 3 patients required simultaneous native kidney nephrectomy at the time of transplant. 25 patients had multiple renal vessels which were double barreled and anastamosed.4 patients had lower urinary tract abnormalities requiring simultaneous/subsequent repair. Overall, 4 patients underwent 2nd transplant. All the donors underwent laparoscopic nephrectomy. Most of the patients had good immediate graft function except in 40 patients, who had delayed graft function;most of them improving over 2 - 6 weeks. 6 Patients had hyperacute rejection and the graft was lost,.4patients had main renal artery thrombosis, Renal allograft biopsy was done in 20 patients. Overall, the Patient survival was 95 %.at 1 year and graft survival 90%. Conclusion(s): Our experience shows that kidney transplantation is a viable and practical option for End stage kidney disease and can be performed even in resource constrained centers in third world countries and the survival rates of patients and the grafts are comparable to other centers across the world. No conflict of interestCopyright © 2023

Venous and arterial thromboses in hospitalized patients with acute COVID-19 at University Hospital Dubrava

Since COVID-19 pandemic has started, there have been reports that SARS-CoV-2 infection induces pro-thrombotic state. Even though the disease presents foremost with respiratory symptoms, high frequencies of both venous and arterial thromboses have been observed while suggesting different molecular mechanisms. University Hospital Dubrava has been Croatia capital's COVID-19 centre for almost a year and a half treating almost 10.000 patients until today. We retrospectively analysed venous and arterial thrombotic events among 4014 patients hospitalized due to COVID-19. Venous thromboembolic events (VTE) occurred in 5.3% and arterial thrombotic events (ATE) in 5.8% of patients. Majority of ATE occurred prior or on the day of admission while VTE were mainly detected during hospitalization (screening). Majority of both occurred prior to intensive care unit (ICU) admission, but both were associated with higher need for ICU care and prolonged immobilization. In multivariate logistic regression analysis independent factors associated with VTE were metastatic malignancy, known thrombophilia, higher D-dimers, longer duration of disease on admission, bilateral pneumonia, longer duration of hospitalization and immobilization for at least one day. On the other hand, factors that showed to be associated with ATE were less severe COVID-19, higher Charlson comorbidity index, history of arterial diseases, aspirin use, lower C reactive protein, better functional status on admission and immobilization for at least one day. In conclusion, venous and arterial thromboses differ in all above mentioned factors thus leaving room for appropriate prevention, intervention and treatment.

Beware of the Unexpected: Acute Coronary Thrombosis Following the Mildly Symptomatic COVID-19 Infection and Two Different Therapeutic Options

COVID-19 infection was declared a pandemic in March 2020 and is responsible for high morbidity and mortality around the globe. Although the most common clinical presentation is respiratory, cardiac complications are common and create new challenges for healthcare. We discuss two mildly symptomatic outpatients with COVID-19 presenting with acute ST-elevation myocardial infarction (STEMI) and high coronary thrombus burden without atherosclerotic plaque. Our report describes two different therapeutic approaches that illustrate the challenges encountered in the management of disseminated coronary thrombosis in patients with STEMI and COVID-19. Clinicians should be aware of the high pro-coagulant state caused by COVID-19, even in mildly symptomatic outpatients, and aggressive pharmacological therapy may be an effective alternative treatment option to percutaneous coronary intervention.Copyright © 2023, CKS.

Effect of therapeutic dose anticoagulation vs prophylactic dose anticoagulation in reducing venous thromboembolism, arterial thrombosis or death events among hospitalized non-critically ill COVID19 pt

Background: Coagulopathy-associated thrombotic events, leading to venous and arterial thromboembolism are highly prevalent among COVID-19 patients. While pharmacologic thromboprophylaxis are the mainstays of treatment, the consideration for an escalated therapeutic dose anticoagulation in the non-critically ill remained a highly debated issue. Objective(s): This meta-analysis sought to evaluate whether therapeutic dose anticoagulation among hospitalized non-critically ill COVID-19 patients reduce the composite primary efficacy outcome (VTE, ATE or death), and the secondary outcomes of major bleeding risk and progression to intubation and mechanical ventilation compared to prophylactic dose anticoagulation. Methodology: After extensive search, screening based on predefined inclusion and exclusion criteria and critical appraisal by 3 independent reviewers 3 eligible open label RTCs with a total of 1492 patients were included in the study. The event rates of the primary and secondary outcomes were assessed after 21-30 days of hospitalization. Result(s): The Risk Ratio for VTE, ATE and death is higher in the prophylactic dose anticoagulation (RR 1.42;95% CI 1.08-1.86), p-value <0.05) compared to therapeutic dose anticoagulation. The risk for major bleeding (RR 0.70;95% CI 0.30-1.62, p-value >0.05) and progression to intubation and mechanical ventilation (RR of 1.13;95% CI 0.93-1.38, p-value >0.05) were not significantly different between the dosing regimens. Conclusion(s): Therapeutic-dose regimen among non-critically ill admitted COVID-19 patients conferred lower risk for the composite primary outcome of VTE, ATE and death with similar risk for bleeding compared to prophylactic dose regimen. Due to this outcome advantage, therapeuticdose anticoagulation can be considered as initial regimen in the noncritically ill COVID-19 patients in the absence of contraindications.

The features of thrombogenesis in COVID-19-associated pneumonia compared to bacterial pneumonia: the key role of fibrinolysis

The aim was to estimate the autopsy features of COVID-19 comparing with bacterial pneumonia. Material(s) and Method(s): 15 patients died from COVID-19 pneumonia and 13 patients with CABP. On autopsy of COVID-19 patients macroscopically - enlarged, plethoric lungs, exudate with hemorrhagic components, areas of thrombosis, developing fibrosis (Figure 1A). Figure 1B - microscopical changes in COVID-19: artery of medium caliber, branching of the pulmonary artery, vascular endothelial integrity violation, the arrow indicates a pale pink non-nuclear mass in the form of threads - fibrin clot. On autopsy of CABP patients macroscopically - compressed, dense, infiltrated lungs, filled with purulent exudate (Figure 1C). Figure 1D demonstrates an example of microscopical changes in CABP: mixed thrombi in the lumen of the arteries, more often in average caliber were found. This thrombus had a head (the structure of a white thrombus), a body (actually a mixed thrombus) and a tail (the structure of a red thrombus). The head was attached to the endothelial lining of the vessel, which distinguishes a thrombus from a posthumous blood clot or from an embolus. Conclusion(s): 1) problems in fibrinolysis system, which is the main difference between CABP;in died patients with COVID-19 pneumonia the level of PAI-1 is associated with the disease severity and could be the crucial marker for patients' distribution. (Figure Presented).

Multifaceted COVID-19 Associated Coagulopathy: A Case Series

The pathophysiology behind Coronavirus Disease-2019 (COVID-19) has remained blur even after more than two years of onset of the pandemic. Apart from pulmonary parenchymal involvement, widespread vascular thrombosis affecting both pulmonary and extra-pulmonary systems has also been seen to contribute to COVID-19 associated morbidity. This vascular manifestation often remains undiagnosed due to non specific and varied symptoms that range from asymptomatic detection to life threatening presentations. A series of six COVID-19 positive (three male and three female) cases who presented with thrombosis of pulmonary, coronary and cerebral vessels despite being on thromboprophylaxis are reported herein. The age of patients ranged from 32 to 80 years. Out of six patients, three had comorbidities. The most common complication was Pulmonary Thromboembolism (PTE, n=3) followed by Brain infarct (n=2) and Myocardial Infarction (MI, n=1). Out of three patients with PTE, one patient had concurrent Deep Vein Thrombosis (DVT). All patients were managed as per guidelines issued by the Ministry of Health and Family Welfare for severe COVID-19 disease. Out of six patients, three patients died and three were discharged. The series highlights the need for high index of suspicion on the part of the treating physician that could aid in early detection and successful management of this potentially fatal condition.Copyright © 2023 Journal of Clinical and Diagnostic Research. All rights reserved.

Comparison of High-Risk Pulmonary Embolism Patients with and without COVID-19

Objectives: There has been a significant increase in pulmonary embolism (PE) cases during the coronavirus disease of 2019 (COVID-19) pandemic. In this study, we aimed to compare the effects of COVID-19 positivity on morbidity and mortality in patients treated with a diagnosis of high-risk PE. Method(s): In this single-center and observational study, patients who were referred to our center with the diagnosis of PE between January 1, 2019 and 2021 were retrospectively evaluated. Patients with moderate- and low-risk PE according to the European Society of Cardiology PE guidelines, those who did not undergo computed tomography pulmonary angiography (CTPA) or the ones who did not accept treatment were excluded from the study. The patients included in the study were divided into two groups, as those with and without COVID-19, and compared in terms of demographic data, comorbidities, symptoms, thromboembolism in vessels other than the pulmonary artery, laboratory parameters, treatments, and prognosis. Result(s): A total of 384 PE cases were identified during the study period. Among them, 322 cases that were in the intermediate or low-risk category, 21 cases who did not undergo CTPA, and one case who did not accept thrombolytic therapy were excluded from the study. A total of 40 cases were included in the study. The groups with and without COVID-19 consisted of 23 and 17 patients, respectively. In the group of patients with COVID-19, inflammatory markers were higher, Wells score was lower, and thromboembolism was seen in vessels other than the pulmonary artery. The two groups were similar in terms of other laboratory parameters, demographic data, comorbidities, symptoms, treatment, and prognosis. Conclusion(s): While the involvement of COVID-19 in PE etiology does not change mortality, it may cause more thrombosis development in both venous and arterial systems outside the pulmonary area by significantly increasing inflammation. However, the lower Wells scores in COVID-19 PE cases in our study indicate that new clinical assessment tools are needed to detect PE risk in COVID-19 patients.©Copyright 2022 by The Cardiovascular Thoracic Anaesthesia and Intensive Care.

The results of thrombectomy from the arteries of the lower extremities in patients infected with SARS-CoV-2 Omicron variant with different severity of respiratory failure.

GOAL: Analysis of the results of thrombectomy from the arteries of the lower extremities in patients with COVID-19 against the background of different severity of respiratory failure. MATERIALS AND METHODS: This retrospective, cohort, comparative study for the period from 05/01/2022 to 20/07/2022 included 305 patients with acute thrombosis of the arteries of the lower extremities against the background of the course of COVID-19 (SARS-CoV-2 Omicron variant). Depending on the type of oxygen support, 3 groups of patients were formed: group 1 (n = 168) - oxygen insufflation through nasal cannulas; group 2 (n = 92) - non-invasive lung ventilation; and group 3 (n = 45) - artificial lung ventilation. RESULTS: Myocardial infarction and ischemic stroke were not detected in the total sample. The highest number of deaths (group 1: 5.3%, n = 9; group 2: 72.8%, n = 67; group 3: 100%, n = 45; p < 0.0001), rethrombosis (group 1 : 18.4%, n = 31; group 2: 69.5%, n = 64; group 3: 91.1%, n = 41; p < 0.0001), and limb amputations (group 1: 9.5%, n = 16; group 2: 56.5%, n = 52; group 3: 91.1%, n = 41; p < 0.0001) was recorded in group 3 (ventilated) patients. CONCLUSION: In patients infected with COVID-19 and on artificial lung ventilation, a more aggressive course of the disease is noted, expressed in an increase in laboratory parameters (C-reactive protein, ferritin, interleukin-6, and D-dimer) of the degree of pneumonia (CT-4 in overwhelming number) and localization of thrombosis of the arteries of the lower extremities, mainly in the tibial arteries.

Pyogenic liver abscesses in liver transplant recipients versus non-transplant population. Outcome and risk factors of patient survival.

Pyogenic liver abscess (PLA) is a life-threatening infection in both liver transplant (LT) and non-LT patients. Several risk factors, such as benign and malignant hepatopancreatobiliary diseases and colorectal tumors have been associated with PLA in the non-LT population, and hepatic artery stricture/thrombosis, biliary stricture, and hepaticojejunostomy in the LT patients. The objective of this study is to compare the outcomes of patients with PLA in LT and non-LT patients and to determine the risk factors associated with patient survival. From January 2000 to November 2020, a total of 296 adult patients were diagnosed of PLA in our institution, of whom 26 patients had previously undergone liver transplantation (LTA group), whereas 263 patients corresponded to the non-LTA population. Seven patients with PLA who had undergone previous kidney transplantation were excluded from this retrospective study. Twenty-six patients out of 1503 LT developed PLA (incidence of 1.7%). Median age was significantly higher in non-LTA patients (p = .001). No significant differences were observed in therapy. PLA recurrence was significantly higher in LTA than in non-LTA (34.6% vs. 14.8%; p = .008). In-hospital mortality was greater in the LT group than in the non-LT group (19.2% vs. 9.1% p = .10) and was identified in multivariable analysis as a risk factor for mortality (p = .027). Mortality rate during follow-up did not show significant differences between the groups: 34.6% in LTA patients versus 26.2% in non-LTA patients (p = .10). The most common causes of mortality during follow-up were malignancies, Covid-19 infection, and neurologic disease. 1-, 3-, and 5-year actuarial patient survival rates were 87.0%, 64.1%, and 50.4%, respectively, in patients of LTA group, and 84.5%, 66.5%, and 51.0%, respectively, in patients with liver abscesses in non-LTA population (p = .53). In conclusion, LT was a risk factor for in hospital mortality, but not during long-term follow-up.

Free floating aorto-iliac thrombosis: A rare complication of COVID-19 pneumonia

Arterial thrombosis encountered during sars-cov2 infections is a rare complication with a poor prognosis compared to venous ones. They generally occur in severe and critical clinical forms of covid19 [1,2]. The physiopathology of arterial thrombosis, even if not completely understood highlights hypercoagulability and excessive inflammation as risk factors with a major role of the endothelial lesions in their occurrence. The presence of cardiovascular risk factors in patients infected with covid19 is also discussed as a predisposing factor for arterial thrombosis [2,3]. We report the case of a North African male patient hospitalized for acute respiratory distress syndrome (ARDS) secondary to covid19 pneumonia, complicated by the occurrence of multiple arterial thrombosis of the aorto-iliac axis with the rare finding of two free floating thrombus in the aorta and the right common iliac artery. Clinically, the patient had developed acute bilateral lower limb ischemia and multi-organ failure and the evolution was dramatic with rapid worsening of the patient…s health and eventually his death. Thromboembolic complications are frequent during covid19 infection but the aortic localization is very rare. Its diagnosis is difficult and it has a poor prognosis. Our objective through this case report is to increase knowledge about arterial thromboembolic events while discussing their link to the sars-cov2 viral infection. © 2022

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