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.

Aortic thrombosis after DVT and PE in a young COVID-19 patient.

A rare case of aortic thrombosis in a young COVID-19 positive patient is presented in this case report. Arterial thrombosis developed despite the administration of anticoagulants for treating DVT and PE. The patient underwent axillobifemoral bypass surgery. Limited surgical surveillance, administered steroids and critical health status resulted in wound site infection and consequent graft removal. Aortic endarterectomy and autovenous-patch plasty were performed after the patient's condition improved. Etiopathogenesis of arterial events in the setting of COVID-19 is not entirely understood. It has been suggested that SARS-CoV-2 infection strongly affects vascular endothelial glycocalyx (VEGLX), causes systemic inflammation - reactive microvascular endotheliosis (SIRME), and consequently results in arterial thrombosis.

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.

Aortic floating thrombi with lower limb ischemia and renal infarct in COVID-19: A remote thromboembolic complication.

As the COVID-19 pandemic continues, its novel complications are being increasingly recognized, and new mechanisms of the disease are being unraveled. Aortic free-floating thrombus is exceptionally rare, and prompt diagnosis is vital to alleviate its detrimental end organ effects. We present a patient who was previously discharged owing to COVID-19 pneumonia, admitted with acute onset of lower limb pain, and was diagnosed with aortic free-floating thrombus ended up with embolic events. Clinicians should be aware of COVID-19-related thromboembolic complications, and close monitoring of patients with risk factors is vital for a timely and accurate diagnosis and management.

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 acute respiratory syndrome coronavirus 2-induced acute aortic occlusion: a case report.

BACKGROUND: Severe acute respiratory syndrome coronavirus 2 infection can lead to a constellation of viral and immune symptoms called coronavirus disease 2019. Emerging literature increasingly supports the premise that severe acute respiratory syndrome coronavirus 2 promotes a prothrombotic milieu. However, to date there have been no reports of acute aortic occlusion, itself a rare phenomenon. We report a case of fatal acute aortic occlusion in a patient with coronavirus disease 2019. CASE REPORT: A 59-year-old Caucasian male with past medical history of peripheral vascular disease presented to the emergency department for evaluation of shortness of breath, fevers, and dry cough. His symptoms started 5-7 days prior to the emergency department visit, and he received antibiotics in the outpatient setting without any effect. He was found to be febrile, tachypneic, and hypoxemic. He was placed on supplemental oxygen via a non-rebreather mask. Chest X-ray showed multifocal opacifications. Intravenous antibiotics for possible pneumonia were initiated. Hydroxychloroquine was initiated to cover possible coronavirus disease 2019 pneumonia. During the hospitalization, the patient became progressively hypoxemic, for which he was placed on bilevel positive airway pressure. D-dimer, ferritin, lactate dehydrogenase, and C-reactive protein were all elevated. Severe acute respiratory syndrome coronavirus 2 reverse transcription polymerase chain reaction was positive. On day 3, the patient was upgraded to the intensive care unit. Soon after he was intubated, he developed a mottled appearance of skin, which extended from his bilateral feet up to the level of the subumbilical plane. Bedside ultrasound revealed an absence of flow from the mid-aorta to both common iliac arteries. The patient was evaluated emergently by vascular surgery. After a discussion with the family, it was decided to proceed with comfort-directed care, and the patient died later that day. DISCUSSION: Viral infections have been identified as a source of prothrombotic states due to direct injury of vascular tissue and inflammatory cascades. Severe acute respiratory syndrome coronavirus 2 appears to follow a similar pattern, with numerous institutions identifying elevated levels of thrombotic complications. We believe that healthcare providers should be aware of both venous and arterial thrombotic complications associated with coronavirus disease 2019, including possible fatal outcome.

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.

Role of vitamin D in the pathogenesis of atheromatosis.

BACKGROUND AND AIMS: Cardiovascular disease is the main cause of death worldwide, but the collective efforts to prevent this pathological condition are directed exclusively to individuals at higher risk due to hypercholesterolemia, hypertension, obesity, diabetes. Recently, vitamin D deficiency was identified as a risk factor for cardiovascular disease in healthy people, as it predisposes to different vascular dysfunctions that can result in plaque development and fragility. In this scenario, the fundamental aim of the study was to reproduce a disease model inducing vitamin D deficiency and atheromatosis in ApoE-/- mice and then to evaluate the impact of this vitamin D status on the onset/progression of atheromatosis, focusing on plaque formation and instability. METHODS AND RESULTS: In our murine disease model, vitamin D deficiency was achieved by 3 weeks of vitamin D deficient diet along with intraperitoneal paricalcitol injections, while atheromatosis by western-type diet administration. Under these experimental conditions, vitamin D deficient mice developed more unstable atheromatous plaques with reduced or absent fibrotic cap. Since calcium and phosphorus metabolism and also cholesterol and triglycerides systemic concentration were not affected by vitamin D level, our results highlighted the role of vitamin D deficiency in the formation/instability of atheromatous plaque and, although further studies are needed, suggested a possible intervention with vitamin D to prevent or delay the atheromatous disease. CONCLUSIONS: The data obtained open the question about the potential role of the vitamins in the pharmacological treatments of cardiovascular disorders as coadjutant of the primary drugs used for these pathologies.

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.

Turn down of acute aortic syndrome cases during COVID-19: Results from UK multicentre studies.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic has restructured the healthcare systems, prioritizing resources to treat COVID-19 patients. The aim of this study was to establish if patients affected by acute aortic syndrome (AAS) had unrestricted access to emergency treatment and evaluate outcome of these patients during the peak of the pandemic. METHODS: This is a retrospective analysis of prospectively collected data between March and June 2020 from 19 participating cardiac surgery centers in the United Kingdom. RESULTS: Among 95 patients who presented with an AAS in the participating centers; 85 (89%) underwent surgery, 7 (7%) were turned down for surgery because of their profile of comorbidities, and 3 (3%) died on transfer. Among the patients treated conservatively, three of them (43%) were alive at 30 days. We observed no significant restriction in access to treatment for AAS during the early months of the pandemic. CONCLUSION: Services for life-threatening aortic surgery patients were maintained during the COVID-19 period through patient selection and timing of surgery. The rate of surgical turn-down was comparable to published figures despite the challenges faced during the COVID-19 pandemic.

Aortic thrombus in patients with severe COVID-19: review of three cases.

Coronavirus disease 2019 (COVID-19) could predispose to both venous and arterial thromboembolism, in an exaggerated immune response to the virus, especially in severe patients. Even though aortic clots are a rare entity, the pro-coagulant nature of COVID-19 is associated with thrombosis in atypical locations and should be considered in patients with severe abnormalities in coagulation parameters. We describe a series of three cases of aortic thrombi diagnosed by computerized tomography (CT) angiography in patients with confirmed SARS-CoV-2 infection.

COVID-19-Related Aortic Thrombosis: A Report of Four Cases.

COVID-19 may predispose patients to an increased risk of thrombotic complications through various pathophysiological mechanisms. Most of the reports on a high incidence of thrombotic complications are in relation to deep vein thrombosis and pulmonary embolism, while the evidence about arterial thrombosis in patients with COVID-19 is limited. We describe 4 cases of aortic thrombosis and associated ischemic complications in patients with severe SARS-CoV-2 infection.