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BACKGROUND: COVID-19 is characterized by a heterogeneous clinical presentation, ranging from mild symptoms to severe courses of disease. 9-20% of hospitalized patients with severe lung disease die from COVID-19 and a substantial number of survivors develop long-COVID. Our objective was to provide comprehensive insights into the pathophysiology of severe COVID-19 and to identify liquid biomarkers for disease severity and therapy response. METHODS: We studied a total of 85 lungs (n = 31 COVID autopsy samples; n = 7 influenza A autopsy samples; n = 18 interstitial lung disease explants; n = 24 healthy controls) using the highest resolution Synchrotron radiation-based hierarchical phase-contrast tomography, scanning electron microscopy of microvascular corrosion casts, immunohistochemistry, matrix-assisted laser desorption ionization mass spectrometry imaging, and analysis of mRNA expression and biological pathways. Plasma samples from all disease groups were used for liquid biomarker determination using ELISA. The anatomic/molecular data were analyzed as a function of patients' hospitalization time. FINDINGS: The observed patchy/mosaic appearance of COVID-19 in conventional lung imaging resulted from microvascular occlusion and secondary lobular ischemia. The length of hospitalization was associated with increased intussusceptive angiogenesis. This was associated with enhanced angiogenic, and fibrotic gene expression demonstrated by molecular profiling and metabolomic analysis. Increased plasma fibrosis markers correlated with their pulmonary tissue transcript levels and predicted disease severity. Plasma analysis confirmed distinct fibrosis biomarkers (TSP2, GDF15, IGFBP7, Pro-C3) that predicted the fatal trajectory in COVID-19. INTERPRETATION: Pulmonary severe COVID-19 is a consequence of secondary lobular microischemia and fibrotic remodelling, resulting in a distinctive form of fibrotic interstitial lung disease that contributes to long-COVID. FUNDING: This project was made possible by a number of funders. The full list can be found within the Declaration of interests / Acknowledgements section at the end of the manuscript.
Subject(s)
COVID-19 , Lung Diseases, Interstitial , Humans , Lung/diagnostic imaging , Lung/pathology , Lung Diseases, Interstitial/pathology , Fibrosis , Biomarkers/analysis , Ischemia/pathology , Post-Acute COVID-19 SyndromeABSTRACT
BACKGROUND: Emerging data and case reports have found coagulation abnormalities and thrombosis as sequelae of infection with SARS-CoV-2 (COVID-19). Case reports have reported thrombotic complications caused by COVID-19-related coagulopathy leading to limb loss. Alarmingly, many of these patients had no underlying vascular disease prior to being infected with COVID-19. Many of these case reports discuss patients developing gangrene in the intensive care unit (ICU). Our study compares the incidence of gangrene in the ICU in COVID-19 patients to baseline inpatient levels prior to the pandemic. METHODS: This retrospective analysis investigates two subsets of patients from a single institution. The first was from 2020 during the COVID-19 pandemic; the second subset was from 2019 before the pandemic. Demographic data and medication history were ascertained for both groups. Primary outcomes measures included extremity gangrene that developed in the ICU, mortality, and major amputation. RESULTS: There were 249 COVID-19 positive patients admitted to the ICU in 2020. In 2019, 1,846 admissions to the ICU took place, of which 249 patients were randomized to chart review. There were 13 cases of gangrene that developed in the ICU, 12 of which took place in 2020. In-hospital mortality was 11.6% in nonCOVID-19 patients in 2019 vs. 41.4% in 2021 (P < 0.001). Only 16.7% of the COVID-19 gangrene patients had previously known arterial disease. Also, patients in the COVID-19 group with gangrene were four times more likely to be smokers (P = 0.004). When the data were stratified to compare between gangrene development and no gangrene development, the combined total gangrene group had longer hospital stays, higher need for blood transfusions, required major amputations, and revascularization. A multivariate logistic regression from the total study similarly demonstrated that COVID-19 infection is associated with an 18.23 times increased risk of gangrene. CONCLUSIONS: COVID-19 has resulted in an incomprehensible societal impact that will linger for years to come. The last 2 years have reinforced that COVID-19 will be a part of our clinical practice indefinitely. This study emphasizes the importance of clinician awareness of COVID-19 induced critical limb ischemia in those without underlying arterial disease and few medical comorbidities. More research efforts toward preventing limb loss and COVID-19 coagulopathy must be performed expeditiously to achieve a better understanding.
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COVID-19 , Humans , COVID-19/complications , Pandemics , Chronic Limb-Threatening Ischemia , Retrospective Studies , Ischemia , Treatment Outcome , SARS-CoV-2 , Intensive Care Units , GangreneABSTRACT
Acute limb ischemia is a vascular emergency and current guidelines emphasize the need for rapid treatment in a vascular center with an option of open surgical and interventional revascularization. Endovascular revascularization options for acute limb ischemia are increasingly focused on a wide range of mechanical thrombectomy devices based on different operating principles.For patients with acute limb ischemia in the setting of covid-19 infection high mortality rates and low technical success rates of revascularization procedures have been described.
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COVID-19 , Humans , Thrombectomy , Ischemia/diagnosis , Ischemia/therapySubject(s)
Arteries , Extremities , Ischemia , Limb Salvage , Veins , Humans , Arteries/surgery , Ischemia/surgery , Veins/surgery , Limb Salvage/methods , Extremities/blood supply , Extremities/surgeryABSTRACT
Clinical manifestations of COVID-19 have changed a lot, ranging from respiratory and Ear, Nose and Throat (ENT) symptoms to extra pulmonary thrombotic, neurological, cardiac and renal complications. We here report the case of two patients with SARS-CoV-2 pneumonia whose course was marked by prolonged upper limb ischemia. The association between venous, but also arterial, thrombotic complications and viral infection is now well established, and appears to be related to hypercoagulability.
Subject(s)
COVID-19 , Gangrene , Humans , Gangrene/etiology , COVID-19/complications , SARS-CoV-2 , Upper Extremity , Ischemia/etiologyABSTRACT
SARS-CoV-2 was detected in China in December 2019. Myocardial injury is a crucial presentation of COVID-19, based on the association of ACE-2 and SARS-CoV-2. Down-regulating ACE-2 decreases the cardioprotective effects of angiotensin, leading to a higher TNF-α activation. TNF-α causes the inflammatory response in the myocardial damage as an apoptotic inducer. Moreover, as an inducer of necroptosis, TNF-α binds to a part of TNF receptor 1, which involves receptor-interacting protein 1 (RIP1) and causes cell death through RIP1 inhibition and NF-κB stimulation, which are also done through Tpl-2. Calcineurin controls the Tpl-2-driven NFAT stimulation. Bcl-2 or Bcl-XL entirely blocks these pathways. Bcl-2 overexpression reduces FasL expression with a mechanism based on Bcl-2 inhibiting the NFAT. Moreover, the Fas/FasL system activates apoptosis in various cells. Bcl-XL stimulates Fas-related cell death. Additionally, TNF-α, as a part of inflammatory cytokine storms, indirectly interacts with NFAT/Bcl-2 through Tpl-2/NF-κB. Diversely, TNF-α and IL-1ẞ, the basis of inflammatory cytokine storms in COVID-19, can stimulate generating NO. Also, IL-2 is highly up-regulated in COVID-19 patients and stimulates NO generation in patients. TNF-α can provoke the generation of superoxides in neutrophils. A well-determined mechanism is the intracellular production of NO via calcium-calmodulin-dependent NO synthase (NOS). NO enhances NFAT’s calcium-dependent activity. Also, Intra/extracellular calcium exchange activates calcineurin and its related molecule, NFAT. Nitration provokes RIP1 necroptosis cascade, with respiratory complex I. Nitrites converse protection against ischemia-reperfusion injuries in the myocardium. Regulating this intrinsic molecular pathway can prevent the necroptosis of cardiomyocytes.
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Cardiomyopathies , Ischemia , Severe Acute Respiratory Syndrome , COVID-19ABSTRACT
BACKGROUND: The purpose of the study was to compare the clinical presentation, management, and outcomes of surgical revascularization for acute limb ischemia (ALI) in 2 groups of patients-with and without SARS-CoV-2 infection. METHODS: During the 2 years (01.01.2020-31.12.2021) all consecutive patients diagnosed with ALI and treated with urgent revascularization were prospectively enrolled. Based on the results of polymerase chain reaction swab for SARS-CoV-2 infection patients were allocated to group A-infected or group B-noninfected. Demographic characteristics, clinical, imaging, laboratory data, and details of treatment were collected prospectively. The composite endpoint of major amputation and/or death at 30 days after surgery was defined as main study outcome. The postoperative ankle-brachial index value, reinterventions, complications, and length of hospital stay were considered as secondary outcomes. RESULTS: Overall, 130 patients (139 limbs with ALI) were analyzed-21 patients (23 limbs) in group A and 109 patients (116 limbs) in group B. The anatomical site of arterial occlusion, duration, and severity of ischemia did not differ significantly between the groups. Patients with COVID-19 had significantly shorter time from ALI onset till administration of the first dose of anticoagulant: 8 (2.5-24) hr vs. 15.7 (6-72) hr in group B, P = 0.02. Vascular imaging was performed before intervention only in 5 (23.8%) infected patients compared to 78 (71.5%) patients in group B, P < 0.001. The main outcome was registered in 38 (29.2%) patients, significantly more frequent in infected cohort: 12 (57.1%) patients in group A versus 26 (23.8%) in group B, P = 0.003. Difference was preponderantly caused by high mortality in group A-9 (42.8%) patients, compared to 17 (15.5%) patients in group B, P = 0.01. The difference in the rate of limb loss was not statistically significant: 4 (17.3%) limbs were amputated in COVID-19 patients and 12 (10.3%) limbs-in noninfected patients (P = 0.3). Combination of ALI and COVID-19 resulted in increased 30-day mortality-risk ratio (RR) 2.7 (95% confidence interval [CI]: 1.42-5.31), P = 0.002, but did not lead to significantly higher amputation rate-RR 1.6 (95% CI: 0.59-4.75), P = 0.32. In group A initial admission of the patient in the intensive care unit was an independent risk factor for amputation/death. Excepting systemic complications which were more frequently registered among COVID-19 patients: 7 (33%) cases vs. 14 (12.8%) in group B, P = 0.04; no differences in other secondary outcomes were observed between the groups. CONCLUSIONS: Study demonstrates the significant negative impact of COVID-19 upon the 30-day amputation-free survival in patients undergoing urgent surgical revascularization for ALI. The difference in outcome is influenced by higher rate of mortality among infected patients, rather than by the rate of limb loss. Severity of COVID-19, namely requirement of intensive care, mostly determines the outcome of ALI treatment.
Subject(s)
Arterial Occlusive Diseases , COVID-19 , Peripheral Arterial Disease , Peripheral Vascular Diseases , Humans , COVID-19/complications , Prospective Studies , Treatment Outcome , SARS-CoV-2 , Peripheral Vascular Diseases/surgery , Ischemia/diagnostic imaging , Ischemia/surgery , Risk Factors , Arterial Occlusive Diseases/surgery , Limb Salvage/adverse effects , Retrospective Studies , Peripheral Arterial Disease/diagnostic imaging , Peripheral Arterial Disease/surgeryABSTRACT
Purpose During the first wave of the SARS-Cov2 pandemic, the use of hydroxychloroquine and azithromycin raised safety concerns in terms of arrhythmias related to QT segment prolongation. The aim of this observational, prospective, single-center study was to describe cardiovascular events in critically ill patients who were mechanically ventilated for SARS-Cov2 pneumonia. Methods Patients included were prospectively monitored for QTc segment prolongation when treated with the association of hydroxychloroquine alone or in combination with azithromycin for Covid-19 pneumonia and treatment had to be stopped before QTc ≤ 500ms. Results 23 patients were prospectively included. Treatment had to be interrupted in 43.5% of patients and more often in the combination group. None of the patients displayed torsade de pointes or sudden cardiac arrest. Forty percent of patients in the combination group experienced atrial fibrillation. Cardiac Troponin I was elevated in 70% of all patients without electric signs of ischemia. Conclusion The association of hydroxychloroquine and azithromycin for treatment of Covid-19 pneumonia mandates the need for prospective evaluation of QTc especially in the presence of biological myocardial injury. The Institutional Review Board waived the need for consent to use prospectively collected clinical data and the study was appointed the serial number 2020-214.
Subject(s)
Arrhythmias, Cardiac , Critical Illness , Ischemia , Cardiomyopathies , Severe Acute Respiratory Syndrome , Cardiotoxicity , Torsades de Pointes , Long QT Syndrome , Heart Arrest , Pneumonia , Atrial Fibrillation , COVID-19ABSTRACT
OBJECTIVE: Hypercoagulability is common in severe acute respiratory syndrome coronavirus 2 and has been associated with arterial thrombosis leading to acute limb ischemia (ALI). Our objective was to determine the outcomes of concurrent coronavirus disease 2019 (COVID-19) infection and ALI, particularly during the Delta variant surge and the impact of vaccination status. METHODS: A retrospective review was performed of patients treated at a single health care system between March 2020 and December 2021 for ALI and recent (<14 days) COVID-19 infection or who developed ALI during hospitalization for the same disease. Patients were grouped by year as well as by pre and post Delta variant emergence in 2021 based on the World Health Organization timeline (January to May vs June to December). Baseline demographics, imaging, interventions, and outcomes were evaluated. A control cohort of all patients with ALI requiring surgical intervention for a 2-year period prior to the pandemic was used for comparison. Primary outcomes were in-hospital mortality and amputation-free survival. Kaplan-Meier survival and Cox proportional hazards analysis were performed. RESULTS: Forty acutely ischemic limbs were identified in 36 patients with COVID-19, the majority during the Delta surge (52.8%) and after the wide availability of vaccines. The rate of COVID-19-associated ALI, although low overall, nearly doubled during the Delta surge (0.37% vs 0.20%; P = .09). Intervention (open or endovascular revascularization vs primary amputation) was performed on 31 limbs in 28 individuals, with the remaining eight treated with systemic anti-coagulation. Postoperative mortality was 48%, and overall mortality was 50%. Major amputation following revascularization was significantly higher with COVID-19 ALI (25% vs 3%; P = .006) compared with the pre-pandemic group. Thirty-day amputation-free survival was significantly lower (log-rank P < .001). COVID-19 infection (adjusted hazard ratio, 6.2; P < .001) and age (hazard ratio, 1.1; P = .006) were associated with 30-day amputation in multivariate analysis. Severity of COVID-19 infection, defined as vasopressor usage, was not associated with post-revascularization amputation. There was a higher incidence of re-thrombosis in the latter half of 2021 with the Delta surge, as reintervention for recurrent ischemia of the same limb was more common than our previous experience (21% vs 0%; P = .55). COVID-19-associated limb ischemia occurred almost exclusively in non-vaccinated patients (92%). CONCLUSIONS: ALI observed with Delta appears more resistant to standard therapy. Unvaccinated status correlated highly with ALI occurrence in the setting of COVID-19 infection. Information of limb loss as a COVID-19 complication among non-vaccinated patients may help to increase compliance.
Subject(s)
COVID-19 Vaccines , COVID-19 , Endovascular Procedures , Peripheral Arterial Disease , Humans , COVID-19/complications , Endovascular Procedures/adverse effects , Ischemia/diagnostic imaging , Ischemia/etiology , Ischemia/therapy , Limb Salvage , Lower Extremity/blood supply , Retrospective Studies , Risk Factors , SARS-CoV-2 , Treatment Outcome , Vaccines , COVID-19 Vaccines/adverse effectsABSTRACT
Patients with COVID-19 demonstrate higher rates of cardiovascular complications, including thromboses and thromboembolism. One may suppose that the action of SARS-CoV-2 transforms stable atherosclerotic plaques into unstable status. Cardiovascular complications in COVID-19 may be caused by progressive viral alteration the blood vessels, including vasa vasorum. A lethal case of ischemic brain disease caused by cerebral atherosclerosis and exacerbated with a stroke during COVID-19 infection is briefly described. The results of autopsy showed perivascular lymphocytic infiltration and signs of vasa vasorum vasculitis with thrombi of adventitial microvasculature. The data discussed in the article are interpreted in context of the concept giving the important role in atherogenesis to vasa vasorum.
Subject(s)
Thromboembolism , Ischemia , Brain Diseases , Intracranial Arteriosclerosis , Atherosclerosis , Stroke , Thrombosis , Vasculitis , Cardiovascular Diseases , COVID-19Subject(s)
COVID-19 , Humans , Child , COVID-19/complications , Intestine, Small , Ischemia/complications , AbdomenABSTRACT
Background: Patients that are affected by severe induced respiratory failure (C-ARDS) formCOVID-19, frequently need deep sedation in order to perform adequate ventilator support. Volatile anesthetics (VAs) constitute a convenient alternative to intravenous molecules, allowing to fine-tune the desired level of sedation. Moreover, VAs might have anti-inflammatory and bronchodilatatory effects, which are particularly appropriate for COVID-19 patients. Methods: In this study, we show the results of a retrospective single-center non-profit observational cohort study. To achieve this, we enrolled patients hospitalized for C-ARDS in the COVID Intensive Care Unit of Hospital Santo Stefano (Prato, Italy) during the period March 2020 - June 2021. A total of 112 patients were enrolled in the study that were all submitted to invasive mechanical ventilation. Participants were divided in two groups: i) Group 1 received the VA sevoflurane and, ii) Group 2 were sedated with propofol and remifentanil. A propensity score matching model (PSM) was applied in order match each treated unit with a non-treated unit of similar characteristics between the two groups. The calculation of PSM was performed considering anthropometric data such as age, sex, body mass index (BMI) and comorbidities such as arterial hypertension, chronic obstructive pulmonary disease (COPD), ischemic heart disease, and chronic kidney damage as covariates. Level of sedation (BIS monitoring), respiratory and ventilator parameters, i.e., PaO2/FiO2, pulmonary static compliance and positive end expiratory pressure (PEEP) and biochemical parameters were evaluated at three time-points: at the time of the invasive ventilation (T1), after 72 hours (T2) and after 7 days (T3). Results: 56 patients who received inhaled sedation with sevoflurane were matched with 56 participants receiving an intravenous sedation by means of PSM. An adequate level of sedation was obtained in both groups. In the sevoflurane group, an increase of PaO2/FiO2 and of the static compliance was observed while mortality was slightly decreased. Conclusions: In this work, we demonstrate that deep sedation of invasively ventilated C-ARDS patients can be effectively obtained with sevoflurane. Interestingly, VA sedation with sevoflurane contributed to enhance respiratory mechanics, which has a clear clinical relevance in C-ARDS patients. In terms of pulmonary compliance, results obtained after three days of starting sedation therapy with sevoflurane demonstrated that static compliance was higher in those who received inhaled sedation. At the same timing, PaO2/FiO2 ratio at the same timing was greater in group 1 than in group 2. Further studies deem to confirm the potential of this treatment in a randomized clinical trial.
Subject(s)
Pulmonary Disease, Chronic Obstructive , Ischemia , Heart Diseases , COVID-19 , Hypertension , Renal Insufficiency, Chronic , Respiratory Distress Syndrome , Respiratory InsufficiencyABSTRACT
Background: The objective of our study was to evaluate baseline characteristics, COVID-19 infection and vaccine type and their association with stroke early after COVID-19 vaccination. Methods: In a retrospective cohort study, we estimated the 21-day post vaccination incidence of stroke among COVID-19 first dose vaccine recipients. We linked the Georgia Immunization Registry with the Georgia Coverdell Acute Stroke Registry and the Georgia State Electronic Notifiable Disease Surveillance System data to assess the relative risk of stroke by vaccine type. Results: About 5 million adult Georgians received at least one COVID-19 vaccine from December 1, 2020 to February 28, 2022: 54% received BNT162b2, 41% mRNA-1273 and 5% Ad26.COV2.S. Those with concurrent COVID infection within 21 days post vaccine had an increased risk of ischemic (OR=8.00, 95% CI: 4.18, 15.31) and hemorrhagic stroke (OR=5.23, 95% CI: 1.11, 24.64) with no evidence for interaction between vaccine type and concurrent COVID-19 infection. The 21-day post vaccination incidence of ischemic stroke was 8.14, 11.14, and 10.48 per 100,000 for BNT162b2, mRNA-1273 and Ad26.COV2.S recipients, respectively. After adjusting for age, race, gender, and COVID-19 infection status there was a 57% higher risk (OR=1.57, 95% CI: 1.02, 2.42) for ischemic stroke within 21 days of vaccination associated with the Ad26.COV2.S vaccine compared to BNT162b2. Conclusions: Concurrent COVID-19 infection had the strongest association with early ischemic and hemorrhagic stroke after first dose COVID-19 vaccination. The Ad26.COV2.S vaccine was associated with a higher risk of early post-vaccination ischemic stroke than BNT162b2.
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Stroke , Ischemia , COVID-19ABSTRACT
BACKGROUND: Juvenile Scleroderma is a rare autoimmune disease of the connective tissue. Its concurrence with COVID-19 can lead to limb ischemia as both disease entities are pro-inflammatory and pro-thrombotic. To date, there is no case report describing the symptomatology and course of disease in patients with juvenile Scleroderma and COVID-19. CASE PRESENTATION: An adolescent with acute limb ischemia presented with a history of generalized hypo-and-hyperpigmented skin lesions and mild, non-productive cough. She tested positive for SARS-CoV-2 on nasopharyngeal swab RT-PCR. Further work-up revealed elevated anti-phospholipid antibodies, anti-nuclear antibody, and D-dimer; low Protein S activity; and evidence of peripheral arterial disease on imaging studies. She was started on peripheral vasodilators, Methotrexate, and anticoagulation. Close monitoring of the affected limbs and other organs involved was done. Control of limb ischemia was achieved after 4 months of regular Cyclophosphamide infusion. Continued multi-disciplinary care was ensured for this patient. CONCLUSION: There is evolving knowledge about the interplay of COVID-19 hyperinflammatory state and rheumatologic disorders. COVID-19 is thought to exacerbate cutaneous manifestations of autoimmune disorders via antigen protein mimicry and cytokine imbalance. Moreover, COVID-19 is characterized by complex hematopathologic processes that put a patient in a hypercoagulable state. Elevated D-dimer can be seen in both COVID-19 and systemic sclerosis owing to their pro-thrombotic sequela. There is scarcity of data on the association of Protein S activity with COVID-19 and systemic sclerosis. More studies need to be carried out to ultimately arrive at a consensus on thrombosis prophylaxis for patients with Scleroderma and COVID-19.
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Autoimmune Diseases , COVID-19 , Scleroderma, Systemic , Thrombosis , Female , Humans , Adolescent , COVID-19/complications , SARS-CoV-2 , Scleroderma, Systemic/complications , Scleroderma, Systemic/diagnosis , Scleroderma, Systemic/drug therapy , Ischemia/etiology , Thrombosis/etiologyABSTRACT
Purpose: To present a case of a kidney transplant recipient with multiple, concurrent signs of retinal and choroidal microvascular dysfunction following mild coronavirus disease 2019 (COVID-19). Observations: An immunosuppressed, 51-year-old male with a history of kidney transplantation at an earlier stage, presented with bilateral conjunctivitis and blurry vision that coincided with a SARS-CoV-2-positive upper respiratory tract infection. On examination, we observed bilateral vitritis as well as choroidal congestion with signs of outer retinal and inner choroidal microvascular dysfunction. Moreover, cotton wool spots, consistent with inner retinal ischemia were noted while the rest of the clinical findings subsided. Conclusions and importance: COVID-19, a multi-systemic disease that primarily affects the respiratory system, has been associated with a number of seemingly diverse ocular phenotypes, where both inflammation and ischemia seem to play role. Moreover, the presence of underlying systemic comorbidities may have an impact on both infection outcomes and the ocular complications of the disease. Kidney transplant recipients that develop SARS-CoV-2 infection may be at higher risk for both choroidal and retinal microvasculopathy with prominent choroidal congestion, pigment epitheliopathy with or without subretinal fluid and hyper-reflective changes in optical coherence tomography suggesting ischemia in different retinal layers.
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Deafness , Ischemia , Eye Diseases , Severe Acute Respiratory Syndrome , Diabetic Nephropathies , Vision Disorders , Labyrinth Diseases , Papilloma, Choroid Plexus , Respiratory Tract Infections , Inflammation , COVID-19 , Pigmentation DisordersABSTRACT
Introduction: Infection with COVID-19 may lead to extrapulmonary pathologies secondary to the systemic inflammatory effects of the virus. Case Description: This case report discusses a 55-year-old female patient who presented with small bowel obstruction (SBO) several months after resolution of a COVID-19 infection. The patient was surgically treated with a small bowel resection, and eventually made a full recovery. Discussion: The pathophysiology of COVID-19-induced SBO can be explained by the prolonged inflammation and coagulation activation in the bowel's vasculature system. Under these circumstances, microthrombosis occurs in the bowel's microvasculature; the affected intestinal tissue becomes ischemic and infarcted. The damaged bowel is eventually replaced with fibrotic scar tissue, thus promoting bowel stricture and subsequent obstruction. Conclusion: COVID-19 can be responsible for both acute and chronic embolic and thrombotic events in the mesenteric vasculature, which acts as a risk factor in the manifestation of SBO.
Subject(s)
COVID-19 , Intestinal Obstruction , Mesenteric Ischemia , Female , Humans , Middle Aged , COVID-19/complications , Mesenteric Ischemia/diagnosis , Intestinal Obstruction/diagnostic imaging , Mesentery , Ischemia/diagnosisABSTRACT
Purpose: This paper summarises the results of 4 national surveys on the numbers, utilisation and technique of myocardial perfusion SPECT (MPS) from 2012 to 2021. Methods: A one-page questionnaire for information on MPS in 2012, 2015, 2018 and 2021 was sent to German centres practising nuclear medicine. To check for representativeness, the numbers obtained were related to official annual data and furthermore to the numbers of invasive coronary angiography procedures (ICA). Results: MPS examinations increased by > 40% from 2012 to 2021 and showed a centralisation with increasing MPS per centre. In 2020, a mild impact of the Covid-19 pandemia could be observed in the form of only a slight MPS increase, which was compensated in the following year. Outpatient care cardiologists represent the most important referrer (70%). Mostly, 2-day protocols were used. One-day protocols and stress-only protocols showed insignificant changes. The use of exercise stress decreased steadily. In 2021, exercise stress was replaced by pharmacological stress as the most frequent stress modality. Camera systems showed a shift to more SPECT-CT systems. The use of gated SPECT increased to almost 90%. Quantitative scoring showed an increasing acceptance. The ratio of invasive coronary angiographies (ICA) to MPS was between 3.9 and 4.5. A significant proportion of ICA in the context of CCS was performed without prior testing for ischaemia. Conclusion: The 2012 to 2021 MPS surveys reveal a continuously growing number of examinations with only a mild temporary effect of the Covid-19 pandemia and a centralisation with increasing numbers per centre. Performance and technical data reveal a high-grade adherence of MPS practice to the current ESC guideline. A large potential of non-invasive diagnostics remains for the future.
Subject(s)
Cardiomyopathies , Ischemia , COVID-19ABSTRACT
Background The spread of severe acute respiratory syndrome coronavirus 2 has resulted in coronavirus disease 2019 (COVID-19) pandemic, raising significant concerns. COVID-19 can lead to thrombotic complications such as acute limb ischemia (ALI). In patients with COVID-19, thrombotic complications may increase the risk of morbidity and mortality. The frequency of ALI has reduced worldwide, and the hypercoagulable condition remains an infrequent cause of limb ischemia. Patients with COVID-19 have a 35–45% thromboembolic complication rate. In many studies, the virus launches a second attack between 7 and 14 days after symptom onset, possibly causing hypercoagulability. If conservative treatment fails, various surgical methods, including thromboembolectomy, thrombolysis, and thrombosuction, can be performed to treat ALI.Case Presentation: We report the case of a 37-year-old man who presented with a 2 weeks history of right foot pain, toes blackish discoloration, and numbness. He tested positive for COVID-19 10 days prior to his presentation. Computed tomography angiography (CTA) of the lower limbs revealed near-complete occlusion of the right popliteal artery with single-vessel posterior tibial artery runoff. The patient was brought to a hybrid operating room, and diagnostic angiography confirmed the diagnosis. He underwent popliteal artery thromboembolectomy and intraoperative thrombolysis through a posterior approach. A completion angiography demonstrated a patent popliteal artery with a 2-vessels patency to the foot. His postoperative recovery was uneventful. After surgery, the popliteal, anterior tibial, and posterior tibial arteries were all palpable. The patient was discharged home on antiplatelet therapy with frequent postoperative follow-ups during the last 1 year in our outpatient clinic.Conclusions In mild ALI symptoms, unfractionated heparin can be used with vigilant follow-up. Open and endovascular procedures are currently used to treat patients with acute limb ischemia, and technological advancements continue to make interventions easier and safer.
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Hypesthesia , Thromboembolism , Ischemia , Thrombophilia , Intraoperative Complications , Pain , Thrombosis , COVID-19 , Vascular Calcification , Respiratory InsufficiencyABSTRACT
Background Coronary artery disease (CAD) always co-exists with atrial fibrillation (AF). A new delivery of cardiac interventions for patients is needed during or even after the 2019 coronavirus disease (COVID-19) pandemic. This study aimed to evaluate the safety and efficacy of percutaneous coronary interventions (PCI) combined with AF catheter ablation (AFCA) in a single procedure for patients with CAD and AF.Methods From Jan 2020 to Jun 2021, 40 consecutive patients who underwent both PCI and AFCA were retrospectively enrolled for this study. All patients were followed up 1, 3, 6, and 12 months after the procedure. The primary safety outcomes included cardiac tamponade, cerebrovascular accident/stroke, transient ischemic attack (TIA), thromboembolism, myocardial infarction, vascular access site complications, and bleeding. The primary efficacy outcomes included 12-month AF recurrence and in-stent restenosis (ISR).Results Six adverse events were reported, including small hematoma at the groin access site in two cases, minor bleeding in three cases, and stroke not related to the procedure in one case. No ISR was reported. The Kaplan-Meier analysis estimated that the AF-free success rate at 12 months was 95.7% in paroxysmal atrial fibrillation (PAF) patients and 64.7% in those with persistent atrial fibrillation (PsAF).Conclusions The combination of PCI and AFCA in one procedure was feasible, safe, and efficacious in patients with CAD and AF. The combined procedure can be recommended in clinical practice, during or even after the COVID-19 era.