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

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

Aortic Thrombosis following COVID-19: A Systematic Review.

BACKGROUND: Arterial and venous thromboses associated with the coronavirus disease 2019 (COVID-19) have been well described. These events are caused by a hypercoagulable state due to endotheliopathy and infection-driven coagulopathy. There has been an ever-increasing number of documented cases of aortic thrombosis (AoT) in COVID-19 patients. We conducted a systematic review of current scientific literature to identify and consolidate evidence of AoT in COVID-19 patients. METHODS: A systematic review of literature was conducted between March 15, 2020, and May 1, 2021, on PubMed and Cochrane databases. Additionally, a case from our facility was included. RESULTS: A total of 38 studies (12 case series and 26 case reports) and a case from our facility describing AoT in 56 COVID-19 patients were included. Patients were aged 64.8 ± 10.5 years, were predominantly male (75%), and had several comorbidities. AoT was symptomatic in 82,14% of patients; however, when D dimers were reported, they were significantly elevated even in otherwise asymptomatic patients. Most patients had no previous history of aortic disease. Thrombosis was described in all parts of the aorta, with several cases reporting multiple locations. The median reported time until development of AoT was 10 days. Peripheral thrombosis occurred in 73.21% of cases, most commonly causing lower limb ischemia. Mortality rate was 30.4%. CONCLUSIONS: AoT can occur with no clinical symptoms or as a primary symptom in otherwise asymptomatic COVID-19 patients. D dimers are a highly sensitive diagnostic tool. Diagnosis of this condition prior to development of complications could be instrumental in saving many lives.

COVID-19 and aorto-enteric fistula.

We present the case of a 72-year-old male with upper gastrointestinal bleeding. He had been discharged from hospital two weeks before after severe COVID-19 infection, treated with lopinavir-ritonavir (L-R), hydroxychloroquine, tocilizumab, and methylprednisolone. On presentation, he was in hypovolemic shock. Esophagogastroduodenoscopy showed an ulcer in the third duodenal portion, which was sclerosed and hemodynamic stability was recovered. A scan was performed as it was in an atypical location for ulcers, showing an aortic aneurysm in close relationship to the duodenum, suggesting a primary aortoenteric fistula (PAEF).

Large mural thrombus in the non-aneurysmal and non-atherosclerotic ascending aorta: a case report.

BACKGROUND: The mural thrombus in the ascending aorta is rare, most of which are associated with aneurysm or atherosclerotic lesions, with high risks of causing catastrophic thrombotic events. A mural thrombus in the non-aneurysmal and non-atherosclerotic ascending aorta is exceptionally uncommon. CASE PRESENTATION: We reported a large mural thrombus in normal ascending aorta of an asymptomatic patient. Preoperative imaging confirmed the presence of the sessile thrombus located at the left anterior wall of ascending aorta. Given that it had the potential to cause fatal thrombotic complications, surgical removal and segment of ascending aorta replacement were executed. The patient had an uneventful recovery and discharged 14 days after surgery. CONCLUSIONS: Anticoagulant is the therapeutic cornerstone of ascending aortic thrombus, but surgery should be performed aggressively when the thrombus is large or floating to avoid severe embolic complications or recurrence.

COVID-19-related Abdominal Aortic Thrombosis.

Thrombotic complications increase in novel coronavirus disease 2019 (COVID-19) patients. Most of these complications are associated with venous thromboembolism and pulmonary embolism; and arterial thrombosis is rare. Usually, arterial thrombosis affects peripheral arteries. The involvement of large vessels, such as aorta, is rare in the literature. Major artery thrombosis manifests with different additional complications. Contrast-enhanced abdominal computed tomography angiography (CTA) was performed on a patient, who was followed-up with COVID-19 due to gastrointestinal symptoms. Supra-celiac aortic thrombosis and splenic infarction were detected. This case is reported to share experience regarding our treatment approach in the light of the literature data. Key Words: Arterial thrombosis, Acute aortic thrombosis, COVID-19.

Two-year single centre results with covered endovascular reconstruction of aortic bifurcation (CERAB) in the treatment of extensive aorto-iliac occlusive disease.

OBJECTIVE: To report the results of a single-centre in the treatment of extensive aorto-iliac occlusive disease (AIOD) by the covered endovascular reconstruction of aortic bifurcation (CERAB) technique. METHODS: A retrospective analysis was conducted on data obtained from the review of medical charts of all consecutive patients treated with CERAB technique for AIOD between January 2016 and December 2019 in San Giovanni-Addolorata Hospital (Rome, Italy). Clinical examination, duplex ultrasound with ankle-brachial index measurement and contrast-enhanced computed tomography angiography were performed preoperatively. A clinical and ultrasound follow-up was carried out at one month and then half yearly after the intervention to evaluate patients' clinical status, limb salvage, target lesion revascularization rate, primary and secondary patency rate. RESULTS: During the study period, 24 patients (14 men, 58.3%; 10 women, 41.7%; median age 59 years, range 37-79 years) underwent CERAB for AIOD (TASC II C 29.2%, TASC II D 70.8%). Indications for treatment were: intermittent claudication in 18 patients (75%) and critical limb ischemia in 6 (25%). Technical success was achieved in all cases. Perioperative minor complications occurred in three cases (12.5%). One patient reported an intraoperative iliac rupture requiring adjunctive covered stenting. Median hospital length of stay was two days (range 1-9). No patient died perioperatively nor at the last follow-up. At a median follow-up of 18 months (range 6-48 months), mean ankle-brachial index increased significantly (from 0.62 ± 0.15 before the procedure to 0.84 ± 0.18) (P < 0.001) and target lesion revascularization rate was 12.5%. At two years, the limb salvage rate was 100%, and primary and secondary patency rates were 87.5% and 100%, respectively. CONCLUSION: CERAB technique demonstrated to be effective at the mid-term follow-up with low rate of complications and short length of stay. Long-term results and more robust data are needed to affirm this technique as the first-line treatment for extensive AIOD. However, it could become the preferred option especially in fragile patients and during contemporary COVID-19 pandemic due to the current limitations in vascular and critical care bed capacity.

Spontaneous Acute Aortic Thrombosis in SARS-CoV-2 Infection.

INTRODUCTION: The SARS-CoV-2 infection is associated with significant morbidity and mortality rates. The impact of thrombotic complications has been increasingly recognized as an important component of this disease. CASE REPORTS: We describe four cases of spontaneous acute aortic thrombosis in patients with SARS-CoV-2 infection observed from March to December 2020 at Fondazione Policlinico Universitario Gemelli IRCCS in Rome, Italy.

Dissecting the Management and Outcomes of Thoracic Aortovascular Disease During the COVID-19 Pandemic.

OBJECTIVE: The COVID-19 pandemic has forced the cancellation of planned surgery and led to significant surgical service reductions. Early intervention in aortovascular disease is often critical and cannot be deferred despite these reductions. There is urgent need to evaluate the provision and outcomes of thoracic aortovascular intervention during the peak of the pandemic. METHODS: Prospective data was collected for patients receiving open and endovascular thoracic aortovascular intervention over two-time points; January-May 2020 and January-May 2019 at three tertiary cardiovascular centres. Baseline demographics, cardiovascular risk and COVID-19 screening results were noted. Primary outcomes were median length of intensive care unit and hospital stay, intra-operative mortality, 30-day mortality, post-operative stroke, and spinal cord injury. RESULTS: Patients operated in 2020 (41) had significantly higher median EuroSCORE II than 2019 (53) (7.44 vs. 5.86, P = 0.032) and rates of previous cardiac (19.5% vs. 3.8%, P = 0.019), aortic (14.6% vs. 1.9%, P = 0.041), and endovascular (22.0% vs. 3.8%, P = 0.009) intervention. There was an increase in proportion of urgent cases in 2020 (31.7% vs. 18.9%). There were no intra-operative deaths in 2020 and 1 in 2019 (P = 1.00). There were no significant differences (P ≥ 0.05) in 30-day mortality (4.9% vs. 13.2%), median intensive care unit length of stay (72 vs. 70 hr), median hospital length of stay (8 vs. 9 days), post-operative stroke (3 vs. 6), or spinal cord injury (2 vs. 1) between 2020 and 2019 respectively. CONCLUSIONS: Despite the increased mortality risk of patients and urgency of cases during COVID-19, complicated by the introduction of cohorting and screening regimens, thoracic aortovascular intervention remained safe with comparable in outcomes to pre-COVID-19.

Trying to Survive A Serious Heart Condition in Time of COVID-19.

The world has suffered over the past year under COVID-19. Unfortunately, people still are getting sick from other, also severe, diseases. Although the COVID-19 infection is present, patients need treatment for other life-threatening conditions. We present the case of a 36-year-old patient with severe infective endocarditis with a large abscess of the aortic root, who also is COVID-19 positive. Definitive diagnostics and treatment were avoided due to COVID-19 infection. In the end, emergent surgery was indicated due to acute cardiac decompensation and the development of heart failure symptoms, and the patient recovered uneventfully after surgery.

Coronary and total thoracic calcium scores predict mortality and provides pathophysiologic insights in COVID-19 patients.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has spread worldwide determining dramatic impacts on healthcare systems. Early identification of high-risk parameters is required in order to provide the best therapeutic approach. Coronary, thoracic aorta and aortic valve calcium can be measured from a non-gated chest computer tomography (CT) and are validated predictors of cardiovascular events and all-cause mortality. However, their prognostic role in acute systemic inflammatory diseases, such as COVID-19, has not been investigated. OBJECTIVES: The aim was to evaluate the association of coronary artery calcium and total thoracic calcium on in-hospital mortality in COVID-19 patients. METHODS: 1093 consecutive patients from 16 Italian hospitals with a positive swab for COVID-19 and an admission chest CT for pneumonia severity assessment were included. At CT, coronary, aortic valve and thoracic aorta calcium were qualitatively and quantitatively evaluated separately and combined together (total thoracic calcium) by a central Core-lab blinded to patients' outcomes. RESULTS: Non-survivors compared to survivors had higher coronary artery [Agatston (467.76 â€‹± â€‹570.92 vs 206.80 â€‹± â€‹424.13 â€‹mm2, p â€‹< â€‹0.001); Volume (487.79 â€‹± â€‹565.34 vs 207.77 â€‹± â€‹406.81, p â€‹< â€‹0.001)], aortic valve [Volume (322.45 â€‹± â€‹390.90 vs 98.27 â€‹± â€‹250.74 mm2, p â€‹< â€‹0.001; Agatston 337.38 â€‹± â€‹414.97 vs 111.70 â€‹± â€‹282.15, p â€‹< â€‹0.001)] and thoracic aorta [Volume (3786.71 â€‹± â€‹4225.57 vs 1487.63 â€‹± â€‹2973.19 mm2, p â€‹< â€‹0.001); Agatston (4688.82 â€‹± â€‹5363.72 vs 1834.90 â€‹± â€‹3761.25, p â€‹< â€‹0.001)] calcium values. Coronary artery calcium (HR 1.308; 95% CI, 1.046-1.637, p â€‹= â€‹0.019) and total thoracic calcium (HR 1.975; 95% CI, 1.200-3.251, p â€‹= â€‹0.007) resulted to be independent predictors of in-hospital mortality. CONCLUSION: Coronary, aortic valve and thoracic aortic calcium assessment on admission non-gated CT permits to stratify the COVID-19 patients in-hospital mortality risk.

Aortic Thrombosis in the Course of Covid-19 Disease; Two Rare Cases.

OBJECTIVE: Acute aortic thrombosis and floating aortailiac thrombus are infrequent clinical conditions with high morbidity and mortality rates. It was observed that; SARS-CoV-2 coronavirus disease (Covid-19) caused a hyperinflammation and hyperimmune state and these conditions can result in a hypercoagulation and eventually thrombotic events might occur. METHODS: Here we presented two covid-19 positive patients with rare aortic thrombotic events. RESULTS: Two patients underwent emergent diagnostic tests including computerized tomographic angiography. Total aortic thrombosis just below the renal arising point was evaluated in one patient, and aortic floating thrombus was evaluated in other patient. But despite initial medical therapies, the clinical conditions of the cases worsened and both patients died while on medical therapy before planned surgical intervention applied. CONCLUSIONS: Covid-19 is not only the disease of lungs and inflammatory system also the disease of coagulation and vascular system. Aortic thrombosis is rare and must be kept in mind in Covid-19 patients with peripheral circulation impairment.

Severe Aortic Thrombosis in the Early Period after COVID-19: Two Cases.

A total occlusion of the aorta is a rare condition; however, while rare, it has a very high mortality rate. Coronavirus disease 2019 (COVID-19) poses serious health problems, including vascular problems. Inflammatory changes produced by viral infections can cause serious disturbances in the coagulation system. Although cases showing a marked increase in thrombotic activity in the venous system have been presented, thrombosis in the arterial system, especially in the aorta, has rarely been reported. Here, we present 2 patients admitted to our hospital with an acute aortic thrombosis.

Acute aortoiliac occlusion in a patient with novel coronavirus disease-2019.

The severe acute respiratory syndrome novel coronavirus-2 pandemic is affecting almost every country in the world. Even if the major symptoms of coronavirus disease-2019 are respiratory, different symptoms at presentation are now recognized. Venous thromboembolism has been reported in infected patients and few but increasing cases of arterial thrombosis have been described. We report a case of acute aortoiliac and lower limb artery occlusions in a patient presenting with severe coronavirus disease-2019 infection. The mechanism of the occlusion seemed to be distal embolization from a floating thrombus in the aortic arch caused by a major inflammatory state and virus infection. The patient underwent aortoiliac and lower limb artery mechanical thrombectomy, but required unilateral major amputation.

Thoracic Aortic Mural Thrombus, Right Ventricular Clot and Pulmonary Embolism in a Patient With COVID-19 Pneumonia.

Since the outbreak of the COVID-19 pandemic, increasing evidence suggests that infected patients present a high incidence of thrombotic complications. We report a 67-year-old-woman admitted for severe acute respiratory syndrome coronavirus 2 infection. Chest CT images showed bilateral ground glass opacities, bilateral pulmonary embolism, right ventricular clot in transit and 2 thoracic aortic mural thrombus. Therapy was initiated with subcutaneous low-molecular-weight heparin, and the patient was discharged at 20 days asymptomatic. Complete resolution of the aortic thrombus was observed in a 1-month surveillance CT angiogram. Our case illustrates vascular complications in a COVID-19 patient and its effective treatment with anticoagulation.