A Probable Covid-19 Case Presented with Acute Upper Limb Ischemia.

The arterial revascularization procedure is still a challenging issue in Covid-19 associated limb ischemia. Herein we aimed to present a case of a 64 year-old woman with acute ischemic signs in upper extremity who was diagnosed as a probable Covid-19 case incidentally after admission. Although late admission and failed recurrent embolectomies lead to an eventful course, intra-arterial thrombolysis seemed to present a benefitable treatment option for our patient.

Treatment-Resistant Acute Upper Limb Ischemia in a Patient With Systemic Lupus Erythematous and Concomitant SARS-CoV-2 Infection: A Case Report.

To describe the case of a young female patient, affected by Systemic Lupus Erythematous, hospitalized for severe SARS-CoV-2 infection pneumonia and presenting a treatment-resistant acute upper limb ischemia. Two days after hospital admission, the patient suffered sudden right upper limb pain associated with mild functional impairment. At physical examination, radial and ulnar pulses were absent, and no flow signal was detected at duplex ultrasound scan. Therefore, an acute limb ischemia diagnoses was posed. Despite several surgical and endovascular revascularization attempts, the patient underwent an above the elbow amputation in 10th postoperative day from first surgical embolectomy, and she died for respiratory failure 25 days after hospitalization. Our case of acute upper limb ischemia seems to confirm that clinical manifestation and fate of thrombotic disorder in COVID-19 patients could be precipitated by concomitant autoimmune diseases.

Misdiagnosed Acute Limb Ischemia in Three Nonhospitalized Patients Recovering From a Nonsevere COVID-19 Infection.

The incidence of venous and arterial thromboembolic complications in COVID-19 patients is significant. The vast majority of COVID-19 patients spend their quarantine at home in a self-isolation condition. The occurrence of Acute limb ischemia (ALI) is a dangerous event that needs prompt diagnosis and management with time-dependent recanalization outcomes. We present a case series of three COVID-19 patients who suffered from ALI that occurred during home self-isolation, and that were diagnosed and treated with a significant time-delay due to COVID-19 social implications.

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.

Histopathologic Evaluation of COVID-19 Patients With Peripheral Arterial Thromboembolism: Does Clot Composition Make Any Sense?

BACKGROUND: Coronavirus disease 2019 (COVID-19) causes thromboembolic complications during or post-infection period despite a lack of conventional risk factors. The study aims to learn fundamental changes in COVID-19 patients who underwent embolectomy in terms of clinical characteristics and clot composition. METHODS: In a retrospective cohort study design, we evaluated 21 patients who underwent embolectomy in our clinic between March 12, 2020, and December 31, 2020. Demographics, characteristics, and laboratory values were abstracted and analyzed. Histopathological assessment was held in the pathology department. RESULTS: Of these 21 patients, 11 (52.3%) were SARS-CoV-2 positive and 10 (47.6%) were SARS-CoV-2 negative. There is no statistical difference in terms of anatomic distribution, diagnostic method, length of hospital stay, amputation or mortality levels. Thromboembolic material of COVID-19 patients include significantly less red blood cell (RBC) (21.2-32.6%; P= 0.01), more lymphocyte (14.1-2.6%; P< 0.001), and more leukocyte (27.1-22.1%; P= 0.05). There was no statistical difference between the fibrin ratio. CONCLUSIONS: Inflammatory cells are prominent in arterial thromboembolic material of COVID-19 patients. A combination of hyperinflammation and prothrombotic status may be responsible for this phenomenon.

Managing Vascular Surgery Emergencies and Referrals During the COVID-19 Pandemic at a Tertiary Centre in Oman.

OBJECTIVES: This study aimed to discuss the different challenges faced while managing emergency vascular surgery cases during the COVID-19 pandemic and how these challenges were overcome. METHODS: This study details 14 emergency cases that were managed during a period of one month from mid-March to mid-April at Sultan Qaboos University Hospital, Muscat, Oman. The cases included acute limb ischaemia, critical limb ischaemia, type B dissection of the thoracic aorta, thoraco-abdominal aneurysm, critical internal carotid artery stenosis, trauma, infected arteriovenous forearm loop graft and thrombosed arteriovenous fistulas. RESULTS: Only one patient was confirmed to have COVID-19. Five were negative for COVID-19 while the remaining eight were not tested. Various strategies on how the vascular surgical team accommodated changes in hospital protocols and nationwide lockdown are discussed in detail. CONCLUSIONS: With the judicious use of personal protective equipment and consumable surgical and endovascular devices, communication with support services and other hospitals and implementation of triage protocols, it was possible to manage vascular surgery emergencies effectively.

Acute pulmonary embolism following acute type A aortic dissection in a patient with COVID-19.

Acute aortic dissection and acute pulmonary embolism (PE) are life-threatening emergencies that can mimic each other at presentation. Immediate and accurate diagnosis of these scenarios is crucial to initiate the appropriate interventions. In this case report we present a 73-year-old patient, who was admitted to our Medical Center with acute type A aortic dissection. She was tested for coronavirus disease 2019 (COVID-19) infection and was found to be positive. During her admission in the COVID-19 designated intensive care unit, she diagnosed with acute PE in the main right and left pulmonary arteries. She underwent surgery that included bilateral pulmonary embolectomy and aortic dissection repair. The patient was discharged from our hospital on the ninth postoperative day without any complications. Frequency of simultaneous presentation of acute aortic dissection and acute PE is increased with a history of coagulation abnormalities as seen in patients with COVID-19.

Axillary artery thrombosis resulting in upper limb amputation as a COVID-19 sequela.

Novel COVID-19 continues to intrigue medical professionals with its varied presentations. Though it affects the respiratory tract primarily, thrombogenesis has been the Achilles' heel. A 44-year-old man diagnosed with COVID-19 presented with upper limb pain at a local hospital and was found to have thrombosis of the right axillary artery. Despite a successful embolectomy at the local hospital, there was re-occlusion of the axillary artery and the limb became ischaemic. He was referred to our institution by which time the limb became gangrenous above the elbow and had to be amputated. Extensive sloughing of the nerves was also seen in the local area. Hypercoagulability presenting with various manifestations is common in COVID-19 and needs early anticoagulation. We present this asymptomatic patient who lost a limb to this COVID-19 sequelae.

Mechanical circulatory support for cardiovascular complications in a young COVID-19 patient.

BACKGROUND: The current coronavirus (COVID-19) pandemic is associated with severe pulmonary and cardiovascular complications. CASE PRESENTATION: This report describes a young patient with COVID-19 without any comorbidity presenting with severe cardiovascular complications, manifesting with pulmonary embolism, embolic stroke, and right heart failure. CONCLUSION: Management with short-term mechanical circulatory support, including different cannulation strategies, resulted in a successful outcome despite his critical cardiovascular status.

Superior Mesenteric Artery Thrombosis and Acute Intestinal Ischemia as a Consequence of COVID-19 Infection.

BACKGROUND The novel COVID-19 disease caused by the SARS-CoV-2 virus is a highly infectious disease that originated in Wuhan, China, and has rapidly spread throughout the world. In addition to respiratory complications, the virus has also been implicated in damage to other organ systems as well as coagulopathy. The present report describes the first presumptive case of COVID-19-associated acute superior mesenteric artery thrombosis and acute intestinal ischemia. CASE REPORT A 55-year old man presented to the emergency department with nausea, generalized abdominal pain and diarrhea; he denied having a fever or any respiratory symptoms. Computed tomography (CT) of the abdomen and pelvis revealed bilateral pulmonary ground-glass opacities. He tested positive for SARS-CoV-2, and was treated with hydroxychloroquine, azithromycin and ceftriaxone, and was discharged home after five days of inpatient treatment. One week later, the patient returned with recurrent nausea, vomiting and worsening diffuse abdominal pain. A CT scan of the abdomen showed a 1.6-cm clot, causing high grade narrowing of the proximal superior mesenteric artery and bowel ischemia. The patient emergently underwent exploratory laparotomy, thromboembolectomy and resection of the ischemic small bowel. A post-operative complete hypercoagulable workup was unrevealing. CONCLUSIONS Despite the absence of respiratory symptoms, patients infected with SARS-CoV-2 may show atypical presentations, such as gastrointestinal symptoms. Clinicians managing patients with suspected or confirmed SARS-CoV-2 infection during the COVID-19 pandemic should monitor these patients for potential complications that may arise from this disease.

Pulmonary embolism in acute medicine: a case-based review incorporating latest guidelines in the COVID-19 era.

Pulmonary embolism remains an important cause of morbidity and mortality in the UK, particularly following the outbreak of the novel coronavirus 2019 (COVID-19), where those infected have an increased prevalence of venous thromboembolic events. The pathophysiology in COVID-19 patients is thought to relate to a thromboinflammatory state within the pulmonary vasculature, triggered by the infection, but other risk factors such as reduced mobility, prolonged immobilisation and dehydration are likely to contribute. Several societies have released comprehensive guidelines emphasising the importance of risk stratification in patients with acute pulmonary embolism. They advocate the use of clinically validated risk scores in conjunction with biochemical and imaging results. Patients with mild disease can now be managed in the outpatient setting and with newly developed therapies, such as catheter-directed thrombolysis, becoming available in more centres, treatment options for those with more severe disease are also expanding. This article presents four theoretical but realistic cases, each diagnosed with acute pulmonary embolism, but differing in levels of severity. These demonstrate how the guidelines can be applied in a clinical setting, with particular focus on risk stratification and management.

Acute Pulmonary Embolism in SARS-CoV-2 Infection Treated With Surgical Embolectomy.

A cluster of pneumonia cases caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread rapidly throughout China, Europe, and the United States. The pneumonia might evolve to acute respiratory distress syndrome, requiring assisted mechanical ventilation. The prolonged immobilization combined with respiratory failure, sepsis, and dehydration might expose SARS-CoV-2 patients to increased risk of complication, including pulmonary embolism. We report a case of SARS-CoV-2 complicated by a massive pulmonary embolism in a patient who underwent successful surgical embolectomy. We believe that maintaining the same proactive attitude suggested by current European Society of Cardiology and European Respiratory Society guidelines might help in reducing morality and improving survival in SARS-COV-2 patients.

Severe Acute Proximal Pulmonary Embolism and COVID-19: A Word of Caution.

Acute pulmonary embolism is an uncharacteristic presentation in patients with coronavirus 2019 (COVID-19). Here we describe the case of a young woman presenting with severe pulmonary embolism, without any associated symptoms of infections. A clot in a patent foramen ovale was noted. Despite emergency surgical embolectomy, her clinical conditions continued to deteriorate. She was put on extracorporeal life support and tested positive for COVID-19. She died of multiorgan failure on day 10. COVID-19 may have a thrombogenic effect, and it may need to be considered in cases of pulmonary embolism and in the absence of any obvious risk factor.