Telemedicine technologies in improving the effectiveness of followup monitoring of patients with lower extremity peripheral artery disease during the COVID19 pandemic.

Aim. To evaluate the effectiveness of a novel approach to followup monitoring of patients with lower extremity peripheral artery disease (PAD) using telemedicine technologies. Material and methods. The study included 175 patients (mean age, 68, 1+/-7, 7 years). Two following groups of patients were formed: the main group (n=86), which used an optimized monitoring program using telemedicine techniques, and the control group (n=89), which assumed traditional monitoring by a cardiologist and a vascular surgeon. The mean followup period was 11, 77+/-1, 5 months. The optimized monitoring program included the implementation of audio communication with patients by an employee with a secondary medical education with an assessment of the current health status according to original unified questionnaire, with the definition of personalized management tactics. At the primary and final stages, the patient underwent an assessment of clinical and anamnestic data, mental and cognitive status, and compliance. Results. At the final stage, uncompensated hypertension was revealed in 36, 0% and 49, 4% (p=0, 0001), smoking - in 30, 6% and 42, 9% (p=0, 05) in the main and control group, respectively. In the main group, a greater painfree walking distance was revealed - 625, 8+/-395, 3 m (control group - 443+/-417 m (p=0, 013)). The average systolic blood pressure was 125, 2+/-10, 2 mm Hg and 138, 8+/-15, 8 mm Hg (p=0, 0001) in the main and control group, respectively. In the control group, a greater number of patients with a high level of personal and situational anxiety were revealed (p=0, 05). In the main group, a higher level of adherence to therapy was established at the final study stage (p=0, 001). Conclusion. The optimized monitoring program for patients with limited mobility is effective and can be implemented in practical healthcare for patients with lower extremity PAD.Copyright © 2023 Vserossiiskoe Obshchestvo Kardiologov. All rights reserved.

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

A UNIQUE CASE: ACUTE EOSINOPHILIC PNEUMONIA SECONDARY TO DAPTOMYCIN: A COVID-19 PNEUMONIA MIMIC

SESSION TITLE: Drug-Induced Lung Injury Pathology Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Acute eosinophilic pneumonia (AEP) is an atypical cause of acute hypoxic respiratory failure in adults, however if not identified can prove to be fatal. It can all be a COVID19 mimic during the pandemic. AEP has several causes, such as inhalational drugs, infections and various pharmaceuticals. Often, patients will have an acute respiratory syndrome for less than one-month, pulmonary infiltrates on chest computed tomography (CT) or radiography (CXR), in addition to bronchoalveolar lavage (BAL) with more than 25% of eosinophils. CASE PRESENTATION: A 79 y/o man underwent an elective total knee replacement complicated by acute lower limb ischemia from an occluded bypass graft. He developed methicillin-resistant Staphylococcus aureus (MRSA) and Vancomycin-resistant Enterococcus (VRE) joint and soft tissue infection of the lower extremity. He was prescribed a 6-week course of Daptomycin. He presented about 3 weeks into treatment with shortness of breath. He was initially diagnosed with acute on chronic congestive heart failure (CHF) exacerbation and COVID negative. He was initially treated with diuretics. He developed acute renal failure requiring dialysis and acute hypoxic respiratory failure requiring intubation. CXR revealed bilateral lung infiltrates with BAL having 80% eosinophils, eosinophilia and urinalysis positive for eosinophils. Daptomycin was discontinued and he was started on systemic steroids for a two-week course. He was successfully extubated 5 days after diagnosis of AEP and was subsequently discharged to a rehabilitation facility on lifelong Doxycycline for MRSA prosthetic joint infection prophylaxis. DISCUSSION: AEP related to Daptomycin was first reported in 2007, in a patient that developed the condition after receiving treatment for endocarditis. Daptomycin caused an inflammatory reaction within the lungs, due to an accumulation of the drug within the pulmonary surfactant. Our case report patient met all components for AEP diagnosis, in addition to symptom onset being approximately 3 weeks into treatment. The ultimate treatment for AEP is to stop the reversible cause, if identifiable, along with glucocorticoids and symptomatic support. Prognosis for patients with AEP is excellent when diagnosis is prompt, and usually infiltrates are resolved within 1 month without long term adverse pulmonary effects. Our patient was discharged to an acute rehab facility without supplemental oxygen therapy and continues to improve from functional standpoint. This case a definite cause of AEP from Daptomycin presented as COVID19 pneumonia mimic. It highlights the importance of rapid diagnosis to prevent morbidity and mortality. CONCLUSIONS: The differential in a patient with acute hypoxic respiratory failure is numerous, especially during the COVID19 pandemic. During these challenging times, it is important to think of atypical causes, such as AEP to improve the patient's clinical status. Reference #1: Allen JN, Pacht ER, Gadek JE, Davis WB. Acute Eosinophilic Pneumonia as a Reversible Cause of Noninfectious Respiratory Failure. N Engl J Med. 1989;321:569-574 Reference #2: Hayes Jr. D, Anstead MI, Kuhn RJ. Eosinophilic pneumonia induced by daptomycin. J Infect. 2007;54(4):e211-213. Reference #3: Rachid M, Ahmad K, Saunders-Kurban M, Fatima A, Shah A, Nahhas A. Daptomycin-Induced Acute Eosinophilic Pneumonia: Late Onset and Quick Recovery. Case Reports in Pulmonology. 2017. DISCLOSURES: No relevant relationships by Moses Bachan No relevant relationships by Zinobia Khan No relevant relationships by Kaitlyn Mehern

Critical leg ischemia related to COVID 19 in doubly vaccinated patients

Background: COVID and venous thromboembolism in unvaccinated population is now a well-established entity but this case is unique as the 1) patient had both COVID vaccines and then tested positive for COVID and 2) presented with vague symptoms and had minimum oxygen requirement 3) developed arterial thromboembolism and acute leg ischemia after 4 days of admission leading to limb amputation ultimately. Data on COVID and COVID vaccine's association with Arterial thromboembolismstill needs to be explored. In our case it was challenging to establish whether the thromboembolism was a complication of vaccine, COVID or was that the result of synergistic interaction of both. Case Presentation: 61 Years old gentleman presented to Emergency Department with vague history of lethargy ongoing for 3-4 weeks and no significant prior co-morbid except sickle cell trait. He had received both doses of COVID vaccine 2 months before presentation and denied any shortness of breath, cough, fever or pain. On presentation he was de-saturating to 77% on Room air and had bilateral crepitations in his chest with PO2 of 7.4 kPa on ABG and raised inflammatory markers on bloods. His CXR showed changes consistent with COVID and he was started on Dexamethasone. His COVID test came back as positive. Throughout his staymaximumamount of oxygen required by him was 36% day1 which improved to 28-32% later, he had not been tachypneic or tachycardiac. His d-dimer was raised at 3000 which was thought to be COVID related, and the decision was taken to perform CTPA to rule out Pulmonary embolism if oxygen requirement worsens. His oxygen requirement continued to remain static with a little improvement or worsening. His inflammatory markers also got better. On Day 4 Patient complained of Right Leg pain. On further enquiry he revealed pain has been ongoing for last 2-3 weeks. His legs were bilaterally ice cold to touch and had hair loss in bilateral legs, pulses in both legs down the femoral artery were not palpable bilaterally. His blood gas Lactate was 2.6 with worsening inflammatory markers but no fever spikes or worsening in oxygen requirement or any other symptoms apart from leg pain. He was immediately seen by vascular Surgery team and was started on therapeutic anticoagulation suspecting acute leg ischemia. CT Angio report showed: Occlusion of Right iliac system, common femoral artery part of the SFA and all the popliteal artery and tibial vessels and unstable thrombus in the left common iliac artery causing severe stenosis and occluded left TP trunk. He was continued on therapeutic anticoagulation and then underwent Right iliofemoral embolectomy, on table angiogram, left common iliac angioplasty via left groin approach and right above knee amputation. Postoperatively he remained well and was tested COVID negative later. He was then discharged to Rehab from hospital for further care. Discussion and conclusion: We suggest that COVID patients with significantly raised d-dimers should be investigated for hidden thromboembolic focus in same way in non COVID patients and not just in lungs but in other organ systems as well. There should be some guidelines regarding increased dose prophylaxis or a flowchart to investigate for these thromboembolic association in COVID.

Immune-mediated Acute Limb Ischemia: A Rare Complication of SARS-CoV-19 Infection

Occurrence of acute limb ischaemia (ALI) in patients with SARS-CoV-2 is an uncommon complication. COVID-19 has been associated with thrombotic disease secondary to a hypercoagulable state. COVID-19 appears to cause a hypercoagulable state through mechanisms unique to SARS-CoV-2 and centres on the cross-talk between thrombosis and inflammation. The proposed hypothesis includes a severely heightened inflammatory response that leads to thrombotic inflammation, through a mechanism such as cytokine storm, complement activation, and endothelitis. The innate and adaptive immune responses result in immunemediated thrombosis, leading to thrombotic complications, such as myocardial infarction, pulmonary embolism, deep vein thrombosis, and stroke. The activation of coagulation (D-dimer) and thrombocytopenia are important prognostic markers in SARSCoV- 19 infections. At our institution, we found six patients to have ALI and reviewed their characteristics and outcomes. Our findings showed that in severe COVID-19 disease, the association of ALI had high mortality. Materials and methods: It is a retrospective observational study performed at Bangalore Baptist hospital during the COVID-19 pandemic (August 2020 to August 2021). We report a case series of 6 ALI patients aged between 30 and 55 years. All the patients were tested positive for SARS-CoV-2 disease. All our patients received standard treatment care as per institution protocol for SARS-CoV-2 disease. They were all commenced on therapeutic anticoagulation at admission to ICU. Baseline coagulation profile and inflammatory markers and their trends were followed in all patients. The diagnosis of ALI in all ventilated patients was done clinically by the presence of pallor, pulselessness, acrocyanosis, blisters, and dry care unit with SARS-CoV-2 disease, 6 patients had developed limb ischemia (1.4%). Male and female preponderance was equal. Among 6 patients, 1 was newly detected diabetes mellitus, 2 were diabetic and hypertensive of which one had right upper limb post-polio paralytic sequelae, and the rest had no co-morbidities. The mean duration of ICU stay and mechanical ventilation days was 22 days and 17.8 days, respectively. All the patients had lower limb ischemia of which 3 were unilateral. Discoloration extended up to the ankle joint in almost all cases. As these patients were on the ventilator secondary to severe hypoxemia or vasopressor support, they were managed conservatively. Two patients presented with stroke, pyelonephritis with acute kidney injury, and septic shock requiring high vasopressor support. 5 of 6 patients died during the course of treatment (mortality 83%). All patients showed high inflammatory markers especially D-dimer during the initial development phase of limb ischemia. 1 survived patient required bilateral foot amputation due to dry gangrene. Conclusion: Limb ischemia with tissue necrosis is a dreadful complication and is associated with high mortality. High incidence of thrombosis despite therapeutic anticoagulation raises a question about pathophysiology unique to COVID-19. Evidence of inflammatory-mediated thrombosis and endothelial injury are possible explanations which would support the use of immunotherapy in addition to anticoagulation for the treatment of thrombotic events. Further insight into the cause and management of thrombosis is needed.

Acute ischemia of the lower limb after inactivated Covid-19 vaccine not available in France: about two cases

We report two cases of ischemia of the lower limbs occurring after vaccination against Covid-19, in two patients without etiology for the ischemia. SARS-CoV-2 infection appears to be involved, for which several vascular physiopathological mechanisms have been identified in several studies. In addition, the vaccination against Covid-19 appears to be a risk of occurrence of ischemia of the lower limbs. Dimers were elevated in both patients. One patient underwent a Fogarty catheter thrombectomy;the other patient received an immediate leg amputation with good healing of the stump.

Severe arterial thromboembolism associated with COVID-19 infection

Purpose: The purpose of our report is to present two patients with acute peripheral arterial thrombosis as a result of COVID-19 infection and discuss the unique features of arterial thrombosis in patients suffering from COVID-19. Case Report: We present a 66-year-old female and a 53-year-old male with proven COVID-19 infection who developed acute lower limb ischemia. Common features in both patients were a multi-segment arterial occlusion in previously healthy arteries, developing despite prophylactic anticoagulation about 15 days after the onset of COVID-19 symptoms. Limb salvage was achieved by early diagnosis and expedited thrombectomy. Conclusion: COVID-19 associated arterial thromboembolism has several unique features reflecting the underlying pathogenetic mechanism which involves a combination of coagulopathy and endothelial dysfunction. Clinical vigilance allowing early diagnosis and expedited surgery remains the key to a successful outcome.

A Case Report of Atrial Myxoma in the Time of Corona Presenting with Systemic Embolization

Myxomas are very rare intracardiac benign tumors. They can arise in any of the cardiac chambers, although 75% occur in the left atrium. Atrial myxomas (AMs) show a female predominance with a sex ratio of 3:1. There is a diversity in the clinical presentation;it may resemble many cardiovascular or systemic diseases. Furthermore, it is possible to present as an acute upper or lower limb ischemia or organ infarction due to systemic emboli. Hereby, we report a previously healthy 38-year-old male, who presented to the emergency department with acute pain of both lower limbs, unilateral upper limb, and acute abdomen. A bedside transthoracic echocardiogram was done which showed a mass that was confirmed to be an AM. The patient underwent surgical embolectomy and tumor resection. As this tumor is rare, the duration between the onset of symptoms to finally reaching the correct diagnosis is usually prolonged, and meanwhile, the patient can experience irreversible neurological damage or even death. Hence, we would like to highlight the role of echocardiogram in detecting AMs. In addition, excluding the primary cause of the thrombi, the patient's ischemic pain has a spectrum of differential diagnosis ranging from peripheral vascular disease to COVID-19. We would also like to emphasize the importance of a high index of suspicion by emergency physicians when such cases present.

Acute peripheral arterial thrombosis and Takotsubo cardiomyopathy in a patient with CoViD-19 infection

Background: The most frequent clinical manifestations of CoViD- 19 are related to the respiratory tract. However variable clinical manifestations are often observed ranging from asymptomatic cases to the most serious complications. We report a case showing that the patient's genetic predisposition and comorbidities are likely strong influencer of the severity of CoViD-19 extra-pulmonary manifestations. Description of the case: We report a case of Takotsubo cadiomyopathy in a 81-year old woman affected by CoViD-19 without a pre-existing cardiac condition. After 25 days of hospitalization, the patient experimented fever, respiratory insufficiency and acute right lower limb ischaemia requiring urgent amputation. 4 days later, electrocardiogram and ultrasound showed myocardial suffering and kinetics alterations respectively, suggestive for Takotsubo cardiomyopathy. Despite a gradual recovery of ventricular function, patient's lung function worsened, death occurred at day 34. Conclusions: The patient experimented acute lower limb ischaemia as a vascular complication of virus infection, although it was treated with enoxaparin. We demonstrated that there was a prothrombotic predisposition: levels of homocysteine and anticoagulation proteins C and S were reduced. This case highlights a link between prothrombotic predisposition and CoViD-19-associated peripheral arterial disease.