Endothelialitis, Microischemia, and Intussusceptive Angiogenesis in COVID-19.

COVID-19 has been associated with a range of illness severity-from minimal symptoms to life-threatening multisystem organ failure. The severe forms of COVID-19 appear to be associated with an angiocentric or vascular phase of the disease. In studying autopsy patients succumbing to COVID-19, we found alveolar capillary microthrombi were 9 times more common in COVID-19 than in comparable patients with influenza. Corrosion casting of the COVID-19 microcirculation has revealed microvascular distortion, enhanced bronchial circulation, and striking increases in intussusceptive angiogenesis. In patients with severe COVID-19, endothelial cells commonly demonstrate significant ultrastructural injury. High-resolution imaging suggests that microcirculation perturbations are linked to ischemic changes in microanatomic compartments of the lung (secondary lobules). NanoString profiling of these regions has confirmed a transcriptional signature compatible with microischemia. We conclude that irreversible tissue ischemia provides an explanation for the cystic and fibrotic changes associated with long-haul COVID-19 symptoms.

Acute limb ischaemia: not an uncommon complication of COVID-19 infection.

A new variant of coronavirus (2019-nCoV) causing acute respiratory distress in humans was identified for the first time in 2019, in Wuhan, China. One of the many complications of infection with this coronavirus is hypercoagulopathy, resulting in acute thrombosis; often leading to acute limb ischaemia. Herein, we report 20 cases of COVID-19 with peripheral arterial thrombosis involving either upper or lower limbs. Some patients underwent vascular procedures and most had to undergo amputation at some level. All the cases (n=20) were referred to us during the 8-month period June 2020 to March 2021. The most common age group was between 51 and 60 years, of whom 80% were males; all the patients had diabetes. The right lower limb was most affected (50%); 15 patients underwent embolectomy. Twenty-five per cent of patients presented with wet gangrene. One patient with upper limb thrombosis recovered after embolectomy and did not require any amputation. Eighty-five per cent of patients underwent some form of amputation and the mortality rate was 10%. Arterial thrombosis is one complication patients may develop during COVID-19 illness, which may affect the outcome. Patients with comorbid conditions like diabetes are at higher risk of developing arterial thrombosis during COVID-19 infection. Susceptibility to coagulopathy may continue even after patient discharge and it is important that both patients and treating physicians are aware of this limb-threatening complication and seek early medical attention.

Mesenteric ischemia in patients with COVID-19: an updated systematic review of abdominal CT findings in 75 patients.

BACKGROUND: Acute mesenteric ischemia (AMI) is a less common but devastating complication of COVID-19 disease. The aim of this systematic review was to assess the most common CT imaging features of AMI in COVID-19 and also provide an updated review of the literature on symptoms, treatment, histopathological and operative findings, and follow-up of these patients. METHODS: A systematic literature search of four databases: Pubmed, EMBASE, WHO database, and Google Scholar, was performed to identify all the articles which described abdominal CT imaging findings of AMI in COVID-19. RESULTS: A total of 47 studies comprising 75 patients were included in the final review. Small bowel ischemia (46.67%) was the most prevalent abdominal CT finding, followed by ischemic colitis (37.3%). Non-occlusive mesenteric ischemia (NOMI; 67.9%) indicating microvascular involvement was the most common pattern of bowel involvement. Bowel wall thickening/edema (50.9%) was more common than bowel hypoperfusion (20.7%). While ileum and colon both were equally involved bowel segments (32.07% each), SMA (24.9%), SMV (14.3%), and the spleen (12.5%) were the most commonly involved artery, vein, and solid organ, respectively. 50% of the patients receiving conservative/medical management died, highlighting high mortality without surgery. Findings on laparotomy and histopathology corroborated strikingly with CT imaging findings. CONCLUSION: In COVID-19 patients with AMI, small bowel ischemia is the most prevalent imaging diagnosis and NOMI is the most common pattern of bowel involvement. Contrast-enhanced CT is a powerful decision-making tool for prompt diagnosis of AMI in COVID-19, thereby potentially improving time to treat as well as clinical outcomes.

A Case of Intestinal Perforation Associated with Mesenteric Thrombosis Due to Post-COVID-19 Syndrome.

PURPOSE: We aimed to present a case who developed intestinal ischemia and associated perforation and abscess due to Superior Mesenteric Vein (SMV) thrombosis caused by post-COVID-19 syndrome and discuss the preoperative Computed Tomography (CT) imaging findings used in diagnosis. CASE PRESENTATION: A 58-year-old patient presented to our clinic with a complaint of acute abdominal pain. His CT examination revealed thrombosis in SMV, congestion in the mesenteric venous structures, contamination in the mesentery, and thickening and dilatation of the jejunal loops due to ischemia. The patient had a history of acute COVID-19 infection. He had typical COVID-19 pneumonia findings (peripheral ground-glass opacities in both lung parenchyma predominantly in the lower lobe) on the thorax CT at that time. He was followed up with anticoagulant therapy. During his follow-up, a thoracic and abdominal CT was performed due to recurrent acute abdominal findings. On thorax CT, there was a web-like filling defect consistent with pulmonary embolism, traction bronchiectasis consistent with late findings of COVID-19 pneumonia, and poorly circumscribed subpleural ground glass opacities. On abdominal CT, in addition to mesenteric ischemia findings, loss of wall integrity was observed in the jejunal loops due to perforation and collection areas containing air consistent with an abscess. He was treated with small bowel resection and abscess drainage. CONCLUSION: Patients with acute COVID-19 infection should be followed up for the early diagnosis of serious symptoms that may develop due to post-COVID-19 syndrome, and contrast-enhanced CT should be the imaging method of choice to detect possible mesenteric vascular thrombosis in patients with acute abdominal symptoms.

Editor's Choice - Update of the European Society for Vascular Surgery (ESVS) 2020 Clinical Practice Guidelines on the Management of Acute Limb Ischaemia in Light of the COVID-19 Pandemic, Based on a Scoping Review of the Literature.

OBJECTIVE: To perform a scoping review of how patients with COVID-19 are affected by acute limb ischaemia (ALI) and evaluate the recommendations of the 2020 ESVS ALI Guidelines for these patients. METHODS: Research questions were defined, and a systematic literature search was performed following the PRISMA guidelines. Abstracts and unpublished literature were not included. The definition of ALI in this review is in accordance with the ESVS guidelines. RESULTS: Most identified papers were case reports or case series, although population based data and data from randomised controlled trials were also identified. In total, 114 unique and relevant papers were retrieved. Data were conflicting concerning whether the incidence of ALI increased, or remained unchanged, during the pandemic. Case reports and series reported ALI in patients who were younger and healthier than usual, with a greater proportion affecting the upper limb. Whether or not this is coincidental remains uncertain. The proportion of men/women affected seems unchanged. Most reported cases were in hospitalised patients with severe COVID-19. Patients with ALI as their first manifestation of COVID-19 were reported. Patients with ALI have a worse outcome if they have a simultaneous COVID-19 infection. High levels of D-dimer may predict the occurrence of arterial thromboembolic events in patients with COVID-19. Heparin resistance was observed. Anticoagulation should be given to hospitalised COVID-19 patients in prophylactic dosage. Most of the treatment recommendations from the ESVS Guidelines remained relevant, but the following were modified regarding patients with COVID-19 and ALI: 1) CTA imaging before revascularisation should include the entire aorta and iliac arteries; 2) there should be a high index of suspicion, early testing for COVID-19 infection and protective measures are advised; and 3) there should be preferential use of local or locoregional anaesthesia during revascularisation. CONCLUSION: Although the epidemiology of ALI has changed during the pandemic, the recommendations of the ESVS ALI Guidelines remain valid. The above mentioned minor modifications should be considered in patients with COVID-19 and ALI.

A case of rapidly progressive upper limb ischemic necrosis in a patient with COVID-19.

BACKGROUND: For more than a year, health systems all over the world have been combating the global coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The disease was first described in the city of Wuhan in China, presenting as an atypical infection of the lower respiratory tract. METHODS: COVID-19 is characterized by multisystemic involvement, and mortality is attributed mainly to the respiratory system involvement, which may lead to severe acute respiratory distress syndrome and respiratory failure. Several COVID-19-associated complications are being increasingly reported, including arterial and venous thromboembolic events that may lead to amputation of the affected limbs. So far, a large number of reports have described hypercoagulability crises leading to amputation of the lower limbs. However, a search of the National Library of Medicine (MEDLINE) revealed no cases of urgent upper limb amputation in COVID-19 patients. RESULTS: This article describes a novel case of upper limb ischemia in a COVID-19 patient, with rapid progression to hand necrosis, requiring urgent through-arm amputation of the upper limb. CONCLUSIONS: This case emphasizes the need for anticoagulant therapy in COVID-19 patients and to maintain a constant awareness of the possible thromboembolic COVID-19-related sequelae.

Ischemic Monomelic Neuropathy: The Case for Reintroducing a Little-Known Term.

Ischemic monomelic neuropathy (IMN) is a little-known, painful axonal neuropathy, secondary to vascular occlusion or steal phenomenon. It typically occurs after vascular bypass, hemodialysis fistulization, or diabetic microvascular disease in the absence of significant clinical features of ischemia. There is limited literature to assist in the characterization and diagnosis of this condition. We describe three patients with IMN with no surgical or peripheral vascular disease history who exhibited spontaneous, persistent foot pain, edema numbness, and weakness with denervation on needle electromyogram in a distal lower leg peripheral nerve distribution. Occlusive disease was found in all patients on angiogram, requiring vascular bypass surgery.

Late Bowel Iischemia and Colovaginal Fistula after Low Anterior Resection in a COVID-19 Patient.

The spread of SARS-CoV-2 in Italy has been rapid, with over 230.000 infections and 33.000 deaths (May 31st, 2020). The full impact of COVID19 on surgery is still unknown, as its effects on healthcare strategy, hospital infrastructure, staff, regional economy and colorectal disease progression, may not be evident before several months. No systematic reports are available about a higher incidence of COVID19 infections in patients with cancer. However, available data indicate that older people are more vulnerable, particularly when there are underlying health conditions such as chemotherapy or active cancer. Herein, we present the case of a patient with rectal cancer treated with pull-through technique low anterior rectal resection and coloanal anastomosis with protective loop ileostomy, complicated with Sars-CoV-2 infection and late (31st post-operative day) colic ischemia with colo-vaginal fistula. Late intestinal ischemia is a rare complication and can be secondary to several traditional factors, but certainly small vessel thrombosis related to Coronavirus disease must be taken into consideration.

Ischemic-hemorrhagic stroke in patients with Covid-19. / Afectación cerebrovascular isquémico-hemorrágica en pacientes con covid-19.

Coronavirus associated severe acute respiratory syndrome (SARS-CoV-2) causes a worldwide syndrome called Covid-19 that has caused 5,940,441 infections and 362,813 deaths until May 2020. In moderate and severe stages of the infection a generalized swelling, cytokine storm and an increment of the heart damage biomarkers occur. In addition, a relation between Covid-19 and neurological symptoms have been suggested. The results of autopsies suggest thrombotic microangiopathy in multiple organs. We present 2 cases of patients infected with severe Covid-19 that were hospitalized in the Reanimation Unit that presented cerebrovascular symptoms and died afterwards. A high dose prophylaxis with antithrombotic medication is recommended in patients affected by moderate to severe Covid-19.

COVID-19 Coagulopathy with Superior Mesenteric Vein Thrombosis Complicated by an Ischaemic Bowel.

COVID-19 coagulopathy is a hypercoagulable state which predisposes to venous, arterial and small vessel thrombosis. We describe a patient with COVID-19 who developed an acute superior mesenteric vein thrombosis with acute intestinal obstruction despite adequate anticoagulation.

Acute upper limb ischemia in a patient with COVID-19.

Patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection mainly present with upper and lower respiratory tract symptoms, with complications related to cytokine storm syndrome and acute respiratory distress syndrome. It has also been described to predispose to venous and arterial thromboembolism; however, limited published data is available regarding thrombosis in coronavirus disease 2019 (COVID-19). Here we are presenting a case of arterial thrombosis in a patient with COVID-19 and a systematic review on coagulopathy associated with COVID-19.