Multisystem Inflammatory Syndrome in Children Requiring ECMO: Anticoagulation strategies and Lessons Learned

Intro: Multisystem Inflammatory Syndrome in Children (MIS-C) is a post-infectious inflammatory response after exposure to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) which can cause acute cardiac dysfunction requiring mechanical circulatory support (MCS). MCS utilization for MIS-C is complicated by a propensity for thrombosis, which threatens circuit integrity. This study describes a cohort of MIS-C patients requiring MCS, their outcomes, and the anticoagulation strategies utilized. Method(s): A retrospective case series of patients diagnosed with MIS-C needing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) at Children's Healthcare of Atlanta from March 1, 2020 to June 30, 2022. VA-ECMO variables, laboratory data, complications, and outcomes were collected. Result(s): Seven patients (all male) with severe MIS-C required VA-ECMO for acute cardiac dysfunction. Median age was 13 years (range 4-15 years). Median ICU stay was 13 days (range 6-17 days) with a median ECMO duration of 7 days (IQR 3-8 days) and median mechanical ventilation duration of 8 days (IQR 5-11 days). All seven patients survived to hospital discharge with good neurologic outcomes. Median time to qualitatively normal ventricular function by echocardiogram was 9.5 days (IQR 3-21 days). Heparin was initially used in 6 patients, bivalrudin initially used in 1 patient, and 1 patient converted from heparin to bivalirudin for refractory systemic thrombosis. Median heparin dose was 206u/kg/d (IQR 192-276u/kg/d) with median anti-Xa levels of 0.75 (IQR 0.1-1.1) and median daily PTT 102 seconds (IQR 83-107 seconds). Median daily PTT of patients receiving bivalirudin was 86 seconds (80-93 seconds). Median R-values by thromboelastography were 38 seconds (IQR 25-55 seconds). Two patients required catheter directed thrombolysis with tissue plasminogen activator (t-PA) for refractory intracardiac thrombi, both were initially started on heparin. Significant cannula thrombosis occurred in 2 patients, 1 initially started on heparin and 1 initially on bivalrudin. Bleeding resulting in compartment syndrome occurred in one patient on heparin requiring fasciotomy of the upper extremities, this patient was not receiving t-PA. Conclusion(s): Anticoagulation management for MIS-C patients requiring ECMO is fraught with challenges. A successful management strategy may necessitate higher heparin assay levels, the use of direct thrombin inhibitors for refractory thrombosis, and the deployment of catheter directed thrombolysis. In this case series, CDT was safely and successfully used in two patients. Further studies are required to understand the optimal anticoagulation strategy for these patients to minimize complications.

Cerebral Venous Sinus Thrombosis Risk Factors, Treatments, and Sequelae: 2011-2019

Introduction: Cerebral venous sinus thrombosis (CVST) is a rare but potentially debilitating thrombosis affecting 3-4 cases per million adults in the United States. Risk factors are thought similar to venous thrombosis, but there is little epidemiologic data corroborating this assertion. Concern about a possible association between the Janssen (Johnson and Johnson) and Oxford-AztraZenaca COVID-19 vaccines and cases of CVST resulted in increased global attention to this condition. Thus, large epidemiological assessment of the risk factors, treatment and outcomes of CVST are needed. Objective(s): Estimate the distributions of risk factors antecedent to CVST diagnosis, report CVST treatments in clinical practice, and potential sequelae of CVST in a large retrospective cohort of adults with CVST in the United States. Method(s): MarketScan Commercial and Medicare Supplemental administrative databases were employed to assess CVST diagnosed between 2011 and 2019 in the U.S. Validated International Classification of Disease (ICD) codes and receipt of an outpatient anticoagulant (either oral or subcutaneous anticoagulant) prescription within 30 days of the ICD code identified incident CVST. Antecedent clinical characteristics, treatments, and sequelae of CVST were identified using inpatient, outpatient, and prescription data. For outcomes, proportions and incidence with 95% confidence intervals (CIs) were calculated, stratified by sex. Result(s): We identified 1,869 CVST patients. Of these 1,314 (70%) were female, with 200 (10%) events identified as a pregnancy-related CVST. The average age was 41 years for females and 48 years for men. Among women, 24.7% were on hormonal therapy (oral contraceptive, estrogen, and progestin) prior to diagnosis. Men had a higher prevalence of comorbidities, such as diabetes (15% men vs. 9% women) and cancer (19% men vs. 10% women). Oral anticoagulant (OAC) use was the most common treatment for CVST in both men (88%) and women (85%) and did not vary by sex. Use of procedures to treat CVST, optic nerve fenestration and catheter directed thrombolysis, were 0.5% and 4.1%, respectively. The most common sequela after CVST was incidence of intracranial hypertension (Incidence: 4.2 per 100 person-years;95% CI: 3.3, 5.1) and palliedema was rare. Conclusion(s): Overall, a majority of CVST patients were women of reproductive age. Our findings suggest a potential association with both endogenous (pregnancy) and exogenous (oral contraceptives, HRT) hormones which needs further study. In our sample, CVST was managed with oral anticoagulants, regardless of sex, and intracranial hypertension was elevated following CVST. This large claims-based analysis is a descriptive insight into the risk factors and management of CVST, a rare and debilitating condition.

Thrombolysis Through Punctured Coronary Balloon and 014 Wire Mediated Guitaring After IVC Filter Insertion in Iliofemoral Deep Vein Thrombosis.

This is a report of a patient who presented with iliofemoral deep vein thrombosis, and was treated with pharmaco-invasive and pharmaco-mechanic methods using coronary balloon and mechanical disruption of clots with coronary 014 wire. A 65-year-old male presented with acute deep vein thrombosis extending from the left common iliac to the popliteal vein. The patient had significant swelling and pain. An inferior vena cava (IVC) filter was inserted, and catheter-directed thrombolysis was planned. A technical difficulty was encountered entering the proximal common iliac vein. Hence, a 014 balance middle weight (BMW) wire with coronary balloon support was introduced through a Cordis® 6 F. diagnostic catheter, and the 014 wire was advanced with guitaring technique up to the femoral vein. Thereafter, the coronary balloon was ruptured at high pressure, and thrombolysis using streptokinase was performed along the balloon tract up to the ostium of the common iliac vein. The patient symptomatically improved significantly and is currently on anticoagulants. Follow-up after one year showed minimal residual oedema, and less pain in the ankle region. Pharmaco-mechanical treatment is possible using coronary balloon dilatations and thrombolysis through a ruptured coronary balloon. Mechanical disruption of clots to some extent is feasible using 014 wire by a guitaring technique. LEARNING POINTS: In difficult cases with deep vein thrombosis, coronary hardware could be used for balloon angioplasty, especially when the iliac bifurcation cannot be crossed.Even suboptimal results can lead to significant symptomatic improvement in deep venous thrombosis treatment.

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.

Muscle Pain in a Patient with Recent Sars-Cov-2 Infection

INTRODUCTION: Thrombosis associated with SARSCoV-2 infection has been well established. Even patients with mild disease, who are able to treat their symptoms at home without supplemental oxygen, are prone to significant sequelae of the disease process. IVC filters, while once considered a standard treatment for deep vein thrombosis (DVT), have fallen out of favor except when there are absolute contraindications for therapeutic anticoagulation due to increased risk of significant adverse events directly correlating with time in-situ including migration, thrombosis, and tears/dissection of the aorta or associated vessels. DESCRIPTION: A 45 y/o F with h/o insulin dependent DM2 and HTN presented for evaluation of bilateral leg cramps with subjective numbness and abdominal pain in the setting of recent COVID-19 infection treated at home. Her exam was notable for significant quadriceps tenderness and induration bilaterally with diminished distal pulses. Initial lab work was significant for lactic acidosis of 6.1, CK 110, and creatinine 2.2. She was admitted to ICU for oliguric AKI and vasopressor support. Broad autoimmune workup was negative. Her renal function continued to deteriorate eventually prompting kidney replacement therapy. Doppler US revealed bilateral DVT in the femoral and popliteal veins. Her CK was monitored daily given continued concern for rhabdomyolysis. CK was >20,000 by day five. Concern for congestive nephropathy prompted CT with contrast of abdomen, pelvis which showed extensive DVT throughout the visualized femoral and iliac veins, extending superiorly past an IVC filter to the inferior margin of the liver. At this time, the patient confirmed she had an IVC filter placed roughly eight years prior after an MVC. The patient underwent successful catheter-directed thrombolysis. Her symptoms slowly improved during her hospitalization which totaled 33 days. The patient was able to discontinue outpatient hemodialysis after 1.5 months. DISCUSSION: It is imperative to obtain complete history in patients with recent COVID as underlying predisposition for thrombosis can greatly increase their morbidity and mortality even with seemingly mild infection. The combination of two highly pro-thrombotic foci in this patient resulted in multisystem sequelae of large IVC and femoral vein thrombosis.

Early-Term Outcomes of Pulmonary Embolism Response Team

Background: Treatment of pulmonary embolism, which is a life-threatening clinical condition, varies according to the different clinical presentations and experiences of the healthcare centers. Pulmonary embolism response teams (PERT) might improve outcomes of pulmonary embolism with faster evaluation and increases the usage of advanced treatment methods. In this study, the effects of PERT in the treatment of pulmonary embolism were investigated. Method(s): Patients diagnosed with pulmonary embolism in our hospital between 01.03.2019 and 28.02.2022 were retrospectively analyzed. Patients, who were diagnosed with PE for the first time and over 18 years of age, were included in the study. The data of the patients was obtained from the patient files. Hospitalization rates, referral rates, treatment approaches, and early-term outcomes were evaluated. Result(s): Nine-eight patients with pulmonary embolism were evaluated by the PERT during the study period. The mean age was 62.8+16.4 years and 59% were male. Nine patients had a history of fracture twelve patients had recently had Covid-19 infection and 6 patients had a history of long-term traveling. Twenty-nine patients had a proven deep venous thrombosis.All patients with intermediate-low risk were treated medically. 59.2% of the patients were hospitalized. The rate of catheterdirected thrombolysis was 37.8% (n=37). Systemic thrombolytic therapy was performed on two patients. One patient with a metastatic brain tumor was treated with low-molecular-weight heparin. Catheter-directed procedures were performed in 37 patients. The time from diagnosis to reperfusion was 243 minutes. There was one pericardial effusion and onemortality. In the 30-day follow- up there was no re-hospitalization and mortality. Conclusion(s): Treatment of pulmonary embolism still varies according to clinical experience. PERT might help with early triage and treatment of patients with pulmonary embolism. Experienced specialists in this team might contribute to clinical recovery by performing advanced treatment methods and decreasing the risk of chronic thromboembolic pulmonary hypertension in the long term and improving the clinical outcomes by increasing quality of life.

A RARE CASE OF ASYMPTOMATIC COVID-19 INFECTION MASQUERADING AS PHLEGMASIA CERULEA DOLENS

SESSION TITLE: Look again: Infections and Mimics SESSION TYPE: Case Reports PRESENTED ON: 10/18/2022 11:15 am - 12:15 pm INTRODUCTION: Phlegmasia Cerulea Dolens (PCD) is a rare and critical condition caused by venous thrombosis requiring emergent treatment to prevent limb ischemia. COVID 19 has been widely reported to cause venous thromboembolism and compromise of tissue perfusion. We report a case of PCD in a patient with asymptomatic COVID-19 infection. CASE PRESENTATION: A 60 year-old female with no known medical history, unvaccinated for COVID-19 presented with sudden onset left lower extremity pain and swelling associated with numbness. Physical examination was remarkable for left lower extremity swelling with bluish discoloration, poikilothermia, and paraesthesia. Computed tomography angiogram (CTA) chest, abdomen and pelvis revealed left lower extremity deep vein thrombosis with compromised blood flow with focal thrombosis of the IVC extending inferiorly to the great saphenous and popliteal vein, along with small bilateral segmental and subsegmental pulmonary emboli. Diffuse Ground glass opacities suspicious for COVID-19 pneumonia. COVID-19 PCR was positive. Anticoagulation with heparin drip was initiated, and the patient underwent successful left iliocaval to popliteal vein thrombectomy and venoplasty by interventional radiology with successful restoration of circulation to the affected extremity. She was eventually transitioned to apixaban. She experienced marked improvement in her symptoms post procedure. DISCUSSION: Patients with COVID 19 develop venous thromboembolisms at an alarming rate despite thromboprophylaxis. The mechanism is likely explained by the virchow's triad (venous stasis, hypercoagulable state, vessel wall injury) in the setting of increased pro-inflammatory markers. We report the first case at our institution of PCD in the setting of COVID-19.We noted that our patient had a similar presentation as those reported in literature, which include acute leg swelling associated with pain and cyanosis. Complications include venous outflow obstruction, which can result in compartment syndrome with arterial ischemia, eventually progressing to gangrene of the affected limb. PCD is a very rare but life-threatening complication caused by extensive clot burden associated with acute limb ischemia and increased mortality rates. This condition requires emergent initiation of intravenous anticoagulation and thrombectomy with or without tissue plasminogen activator (tPA). If this condition is not treated in a timely fashion, it can result in acute limb ischemia and gangrene requiring amputation. CONCLUSIONS: Physicians should recognize PCD in patients who have been exposed to COVID-19 as it is a life-threatening condition which requires emergent initiation of anticoagulation and treatment. Diagnosis is usually made with clinical examination and ultrasonography or CT imaging. Management options include open thrombectomy with leg fasciotomy or catheter directed thrombolysis or percutaneous transluminal angioplasty. Reference #1: Chun TT, Jimenez JC, Pantoja JL, Moriarty JM, Freeman S. Phlegmasia cerulea dolens associated with acute coronavirus disease 2019 pneumonia despite supratherapeutic warfarin anticoagulation. J Vasc Surg Cases Innov Tech. 2020;6(4):653-656. doi:10.1016/j.jvscit.2020.10.002 Reference #2: Gutierrez JR, Volteas P, Skripochnik E, Tassiopoulos AK, Bannazadeh M. A Case of Phlegmasia Cerulea Dolens in a Patient With COVID-19, Effectively Ttreated With Fasciotomy and Mechanical Thrombectomy. Ann Vasc Surg. 2022 Feb;79:122-126. doi: 10.1016/j.avsg.2021.07.034. Epub 2021 Oct 10. PMID: 34644637;PMCID: PMC8502248 Reference #3: : Morales MH, Leigh CL, Simon EL. COVID-19 infection with extensive thrombosis: A case of phlegmasia cerulea dolens. Am J Emerg Med. 2020;38(9):1978.e1-1978.e3. doi:10.1016/j.ajem.2020.05.022 DISCLOSURES: No relevant relationships by Arij Azhar No relevant relationships by Louis Gerolemou No relevant relationships by Wael Kalaji No relevant relationships by Steven Miller N relevant relationships by jasparit minhas No relevant relationships by houman mirtorabi No relevant relationships by Kunal Nangrani No relevant relationships by Gaurav Parhar No relevant relationships by Kiran Zaman

A Proposed Approach for the Management of Clot-in-Transit.

Clot-in-transit (CIT) is defined as a mobile echogenic material in the right atrium or ventricle as observed on ultrasound. A right heart free-floating thrombus is unusual when there is no structural disease of the heart or atrial fibrillation. Cardiopulmonary collapse and quick death can come from CIT, which occurs when a blood clot moves from the heart to the lungs. There are some clinical case reports of a large volume thrombus that was freely floating in the right heart in an asymptomatic patient, and the best therapeutic options are uncertain. Although several trials have been conducted on the treatment of CIT, clinical judgment is still used to determine the best treatment for right heart thrombus (RHT), especially when associated with pulmonary embolism (PE). In this review article, we discuss various diagnostic modalities and treatment options for this rare malady. We studied in detail their clinical impact on patients according to past research studies.

Massive pulmonary embolism post decannulation from Extra Corporeal Membrane Oxygenation: an unexpected complication

Introduction: Massive pulmonary embolism is a rare complication following Veno-Venous Extra Corporeal Membrane Oxygenation (VV-ECMO) decannulation. Management can be challenging. The authors present a case that required VV-ECMO re-cannulation and catheterdirected thrombolysis. Main body: 58-year-old gentleman, background of hypertension and asthma, admitted with severe respiratory failure secondary to COVID-19 pneumonitis. Due to lack of improvement with conventional ARDS treatment, he was referred and retrieved on VV-ECMO. After being off sweep gas for more than 24 hours he was decannulated on day 7. Five hours after decannulation the patient acutely deteriorated. He became tachycardic, hypotensive and hypoxic. A bedside TTE showed severely dilated and impaired right ventricle. The patient was started on milrinone and nitric oxide. Nevertheless, he deteriorated further and became profoundly hypoxic and hypercapnic, and a decision was made to start him on VV-ECMO. A TOE was done to guide cannulation and showed a thrombus in the RV and in the left pulmonary artery. Next day, a CT-pulmonary angiogram (CTPA) was done which showed saddle-shaped pulmonary embolism, with a large occlusive clot in the left main pulmonary artery causing complete non-perfusion of the left lung. After a multi-disciplinary team discussion, the patient had catheterdirected thrombolysis, with some haemodynamic improvement. Within 48 hours, TTE was repeated showing no significant improvement on RV function. CTPA showed very mild decrease of the clot burden. Decision was made to repeat catheter-directed thrombolysis and partial thrombectomy. Repeated imaging revealed decrease in the size of the left main pulmonary artery thrombus. It is thought that the massive pulmonary embolism could have been caused by showering of ECMO cannulas-related thrombi, which were dislodged during decannulation. Patient remained on VV-ECMO for 32 days and was decannulated successfully afterwards and was discharged home on apixaban and long-term pulmonary hypertension follow-up. Conclusion: ECMO cannulas related thrombi are not uncommon complications because of prolonged stay and coagulopathy related to ECMO circuit. However, massive embolism is rarely seen. The use of echocardiography was paramount on the differential diagnosis. In this TTE study, the right ventricle looks significantly dilated with severely impaired both longitudinal and radial functions. Additionally noted septal flattening in systole indicating RV pressure overload, diastolic notching of RVOT doppler trace consistent with significantly raised pulmonary artery pressure and mild to moderate tricuspid regurgitation. Otherwise, the left ventricle is small and has preserved function. (Figure Presented).

Successful Treatment of Paraplegia Caused by Venous Hypertension Secondary to Extensive Iliocaval Deep Venous Thrombosis in the Absence of Phlegmasia Cerulea Dolens

Objectives: Paraplegia is known to complicate extensive iliocaval and lower extremity deep vein thrombosis (DVT) in rare instances. The most common pathophysiology is ischemia from severe venous hypertension in phlegmasia cerulea dolens. Less understood, however, is paresis or paraplegia in the absence of ischemia. We present a case of paraplegia in extensive iliocaval and lower extremity DVT without ischemia, which was successfully treated by percutaneous pharmacomechanical therapy. Methods: A 46-year-old African American woman with a history of hypertension, insulin-dependent diabetes mellitus, indwelling inferior vena cava filter since 2005, and recent coronavirus disease 2019 diagnosis, presented with acute abdominal pain with severe bilateral lower extremity edema, pain, and paresis. She was found to have bilateral iliocaval to tibial DVT (Fig 1). The patient was noted to have multiphasic arterial waveforms on ankle-brachial index and duplex ultrasound examination. Paresis quickly progressed to flaccid bilateral lower extremity paralysis. Neurologic workup was unrevealing. Despite her symptoms, thrombolytic therapy was delayed due to severe menstrual bleeding requiring a blood transfusion. Therapeutic anticoagulation was initiated. Results: On hospital day 10, the patient underwent 24-hour catheter-directed thrombolysis via bilateral popliteal vein access. Bilateral mechanical thrombectomy was then performed, achieving recanalization of the bilateral lower extremities, iliac veins, and inferior vena cava with minimal residual thrombus (Fig 2). The patient's edema and sensorimotor function immediately improved and never incurred lower extremity tissue ischemia. She was discharged on lifelong rivaroxaban. With physical therapy, the patient ambulated independently at 1 month postoperatively. Venous duplex ultrasound examination revealed continued iliocaval and lower extremity patency at 6 months postoperatively. Conclusions: We postulate that this patient suffered lower extremity paralysis secondary to cauda equina syndrome. Pharmacomechanical thrombectomy is a pragmatic means that reestablishes venous patency and relieves venous hypertension. This pathophysiology and its treatment should be considered in extensive iliocaval DVT and lower extremity neurologic compromise despite duration of paralysis. [Formula presented] [Formula presented]

Advances in Percutaneous Management of Pulmonary Embolism.

Acute pulmonary embolism (PE) is a leading cause of morbidity and mortality worldwide. Systemic anticoagulation remains the recommended treatment for low-risk PE. Systemic thrombolysis is the recommended treatment for PE with hemodynamic compromise (massive/high-risk PE). A significant number of patients are not candidates for systemic thrombolysis due to the bleeding risk associated with thrombolytics. Historically, surgical pulmonary embolectomy (SPE) was recommended for massive PE with hemodynamic compromise for these patients. In the last decade, catheter-directed thrombolysis (CDT) has largely replaced SPE in the patient population with intermediate risk PE (submassive), defined as right heart strain (as evidenced by right ventricle enlargement on echocardiogram and/or computed tomography, usually along with elevation of troponin or B-type natriuretic peptide). Use of CDT increased in the last few years due to high incidence of PE in hospitalized patients with coronavirus disease 2019 pneumonia, and the use of mechanical thrombectomy (initially reserved for those with contraindications to thrombolysis) has also grown. In this article, we discuss the value of the PE response team, our approach to management of submassive (intermediate risk) and massive (high risk) PE with systemic thrombolytics, CDT, mechanical thrombectomy, and surgical embolectomy.

Submassive pulmonary thromboembolism, post-COVID sequelae;with mechanical thrombus aspiration and accelerated thrombolysis by Ekos ultrasound with successful resolution

Introduction: Acute pulmonary thromboembolism is a pulmonary pathology that is becoming more frequent nowadays, the use of new mechanical and thrombolytic therapies has a significant impact on the cardiopulmonary prognosis. Case: A 41-year-old male, a retired military man, smoking, overweight, dyslipidemia, alcoholic liver disease, who attended the emergency department due to abrupt dyspnea, with tachycardia, chest pain, and syncope;the patient had tachycardia of 120 bpm, BP 90/60 mmHg and SO2 of 82%, with a history of COVID-19 infection, suspected of massive pulmonary embolism, it was decided to carry out computed tomography where a bilateral submassive pulmonary embolism was documented (Fig. 1A), it was proposed to perform systemic thrombolysis, however due to the risk of bleeding, it was decided to perform EKOS ultrasound directed thrombolysis. Baseline pulmonary angiography was performed with a large number of thrombi (Fig. 1B), distributed in both main right and left branches and deficient pulmonary filling of distal vessels, due to the large amount of thrombus, it was decided to perform manual thrombus aspiration, obtaining a large amount of thrombus (Fig. 1C), as well as thrombolysis in situ with Alteplase a dose of 1 mg/catheter/hour for 12 hours, with a total dose of 24 mg;Ultrasound probe was placed in both pulmonary arteries with the EKOS system (Fig. 1D). Results: Pulmonary angiography was performed 24 hours after the procedure, where no bleeding occurred and almost complete resolution of the thrombus was observed. The patient later with 92% SO2, without oxygen requirements, with HR 90 bpm, with no evidence of ventricular dysfunction, was discharged home with anticoagulation. Conclusion: Low dose fibrinolysis and thromboaspiration are considered, as well as the use of EKOS endovascular ultrasound, a safe and effective procedure, in the context of a patient with high-risk of bleeding, with favorable results that condition clinical and prognostic improvement.

Early Catheter-Directed Thrombolysis without Bowel Resection in Acute mesenteric ischaemia for a Symptomatic COVID-19 Patient

Newer evidence states that COVID-19 pneumonia induces a hypercoagulable state leading to vascular and microvascular thrombotic events. Acute mesenteric ischaemia (AMI) is a potentially fatal vascular emergency with overall mortality of 60%-80%.However, till date, only a few cases of superior mesenteric artery thrombosis in COVID-19 positive patients are reported and most have succumbed to COVID-19 or mesenteric ischemia. Physicians treating COVID-19 usually treat respiratory symptoms and may completely overlook any other uncommon pathology. This case report emphasizes that a patient with early detection and management of acute mesenteric ischaemia being symptomatic for COVID-19 can avoid major bowel surgery and negates any morbidity or mortality associated with the same.

Phlegmasia Cerulea Dolens Secondary to COVID-19 and May-Thurner Syndrome: A Case Report.

Coronavirus disease 2019 (COVID-19) is associated with significant thromboembolic risk. Extensive deep vein thrombosis can infrequently progress to phlegmasia cerulea dolens that carries high morbidity and mortality rates. We report a case of a middle-aged male presenting with phlegmasia cerulea dolens in the context of COVID-19 and underlying May-Thurner syndrome, associated with transiently positive antiphospholipid antibodies.

Catheter-directed thrombolysis in a COVID-19 patient complicated with pulmonary embolism.

Since December 2019, the novel coronavirus (COVID-19) outbreak has become an important public health problem and one of the most common causes of morbidity and mortality worldwide. COVID-19 is highly associated with thromboembolic events, like deep venous thrombosis and pulmonary embolism (PE). Catheter-directed thrombolysis (CDT) provides effective reperfusion for the treatment of PE. We report a patient who was presented with intermediate-risk PE and had a saccular aneurysm of the anterior cerebral artery. The patient was suffered from recent COVID-19 infection and ischemic stroke. As the patient had high bleeding risk for full-dose systemic thrombolytic therapy, CDT was the preferred method for reperfusion. Finally, the patient was discharged from the hospital uneventfully 4 days later. In the setting of high bleeding risk, CDT seems to be an effective and safe approach in patients with intermediate-risk PE.

EkoSonic™ Endovascular System-Directed Thrombolysis in a Patient With COVID-19 Infection Presenting With Bilateral Large Pulmonary Embolism Causing Right Ventricular Strain: A Case Report.

We discuss a case of a 31-year-old male patient who presented to the accident and emergency department with shortness of breath and chest pain since the morning of the day of presentation. His polymerase chain reaction (PCR) test had returned positive for severe acute respiratory syndrome coronavirus 2 (SARS­CoV­2), which causes coronavirus disease 2019 (COVID-19), two weeks ago and his main symptoms had been shortness of breath, dry cough, generalized body pain, and fever. He was not vaccinated against the COVID-19 virus. He had not required hospitalization for COVID-19 and his symptoms had improved on day 10 from the date of diagnosis; however, he developed pleuritic chest pain with shortness of breath on the day of presentation. He was found to have tachypnoea, hypoxia, and tachycardia on assessment. His electrocardiogram showed a right bundle branch block with sinus tachycardia. He underwent a CT pulmonary angiography (CTPA) that showed bilateral large pulmonary emboli extending from the main pulmonary arteries bilaterally extending to the sub-segmental level. There was evidence of right heart strain on the scan. He also had a bedside echocardiogram performed after the CT scan, which showed an enlarged right ventricle but no left ventricular thrombus. His blood results showed D-dimer levels of 14,000 ng/mL and troponin T of 255 ng/L. He received treatment with low molecular weight heparin (LMWH) and underwent emergency EkoSonic™ Endovascular System (EKOS) thrombolysis (Boston Scientific, Marlborough, MA). He remained on ultrasound-accelerated thrombolysis (USAT) for the next 12 hours and showed significant improvement and was taken off oxygen post-EKOS thrombolysis. He was discharged home on oral rivaroxaban after 48 hours of hospital stay; follow-up after two months showed normal-sized right ventricle with no evidence of pulmonary hypertension.

Treatment of acute arterial thrombosis in patients with severe course of new coronavirus infection.

Objective. To study the effectiveness of different treatment methods for patients with the new coronavirus infection COVID-19, complicated by the development of acute arterial thrombosis of various localization. Material and methods. We analyzed treatment outcomes in 14 patients with severe course of new coronavirus infection COVID-19 complicated by acute arterial thrombosis. Open thrombectomy under local anesthesia was performed in 4 patients, endovascular recanalization followed by selective catheter-directed thrombolysis with alteplase — in 2 patients. Seven ones underwent systemic transvenous thrombolysis with recombinant human tissue plasminogen activator (alteplase 100 mg). Two patients underwent intravenous infusion of heparin as etiotropic treatment of acute arterial thrombosis. Results. Mortality rate in patients with arterial thrombosis is much higher (43%) compared to those without vascular complications (mean mortality rate in severe COVID-19 is 21—26%). This fact allows us to consider hypercoagulable state as a predictor of worse prognosis in patients with COVID-19. Conclusion. Various options for systemic and selective catheter-directed thrombolysis are perspective as a promising alternative to open surgical treatment of acute thrombotic conditions associated with COVID-19. Therapeutic measures for acute arterial thrombosis within 48 hours are desirable. (English) [ FROM AUTHOR] Цель исследования. Изучить эффективность лечения пациентов с новой коронавирусной инфекцией COVID-19, осложненной острыми артериальными тромбозами различной локализации. Материал и методы. Проанализированы результаты лечения 14 пациентов с новой коронавирусной инфекцией COVID-19 тяжелого течения, осложненной острыми тромбозами артерий различной локализации. Оперативное лечение в объеме открытой тромбэктомии из артерий под местной анестезией выполнено у 4 пациентов. Эндоваскулярная реканализация артерий с последующим селективным управляемым катетерным тромболизисом альтеплазой была проведена 2 пациентам. Системный трансвенозный тромболизис рекомбинантным человеческим тканевым активатором плазминогена (альтеплаза) в дозе 100 мг был выполнен 7 больным. Системное непрерывное внутривенное введение гепарина в качестве этиотропного лечения острого артериального тромбоза периферического сосудистого русла проведено 2 больным. Результаты. Летальность у больных с артериальными тромбозами значительно выше (43%), чем у пациентов без них (средняя летальность от COVID-19 тяжелого течения составляет 21—26% в общей популяции больных). Этот факт позволяет считать гиперкоагуляционное состояние у больных COVID-19 предиктором худшего прогноза. Вывод. Различные варианты системного и селективного катетерного тромболизиса оправданы в качестве перспективной альтернативы открытым хирургическим методам лечения острых тромботических состояний, ассоциированных с COVID-19. Наиболее перспективным представляется проведение любых лечебных мероприятий по поводу острых артериальных тромбозов на фоне COVID-19 не позднее 48 ч от их развития. (Russian) [ FROM AUTHOR] Copyright of Kardiologia i Serdechno-Sosudistaya Khirurgia is the property of Media Sphere Publishing House and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full . (Copyright applies to all s.)

Endovascular Treatment of Renal Artery Thrombosis in Living-Donor Kidney Transplant Recipient With Severe COVID-19 Disease.

PURPOSE: Coronavirus disease 2019 (COVID-19) patients have a higher prevalence of micro-and macrovascular thrombotic events. However, the underlying mechanism for the increased thrombotic risk is not completely understood. Solid organ transplant recipients infected with SARS-CoV-2 may have an exponential increase in thrombotic risk and the best management strategy is unknown. CASE REPORT: A female kidney transplant recipient presented with allograft's renal artery thrombosis after a recent COVID-19 infection. Due to the risk of kidney failure or exclusion, catheter directed thrombolysis was performed. Residual thrombus was excluded using an endoprosthesis with an excellent result. There were no adverse events and kidney function improved. CONCLUSION: This paper reports the endovascular treatment of renal artery thrombosis in a living-donor kidney transplant recipient with severe COVID-19 disease.

The Outcome of Catheter-Directed Thrombolysis in COVID-19-Associated Deep Vein Thrombosis.

IntroductionPublished evidence of venous thrombotic complications of COVID-19 is lacking from India. This case series consists of twenty-nine adult patients who were COVID -19 positive and treated for Deep Vein Thrombosis (DVT) during the second wave of the COVID-19 pandemic, in India. The study was aimed at analyzing patient demographics of patients with DVT and the outcome of Catheter-Directed Thrombolysis (CDT) in COVID positive patients. Material and Methods: Patients who developed DVT while or after being COVID positive were managed between February and April 2021 at the institution of the first two authors and were included in this retrospective study. Demographic, clinical data, laboratory data, and treatment given were analyzed. All patients were followed up for 3 months with a Villalta score. Results: There were a total of 29 patients (12 male and 17 female) included in the study with a mean age of 47 ± 17 years. The average time of presentation from being COVID positive was 17.8 ± 3.6 days and one patient developed DVT after becoming Covid negative. All but one patient had lower limb involvement, with 42.8% having proximal and 57.2% distal DVT. All patients with Iliofemoral and two with Femoropopliteal DVT were treated with catheter-di thrombolysis and the other 15 patients were managed with anticoagulation alone. No re-thrombosis was observed in the thrombolysis group. Overall average Villalta score at 3 months was 10.7 ± 2.1 with a score of 10.58 ± 2.1 in the anticoagulation-only group and 10.85 ± 2.3 in the CDT group. Conclusion: COVID-19 seems to be an additional risk factor in the development of DVT. The outcome of such patients, treated by thrombolysis appears to be similar to non-COVID patients. In this, observational experience of the authors suggests that CDT could be offered to COVID positive patients with symptomatic Iliofemoral DVT with good outcomes and an acceptable post-intervention Villalta score.