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2.
Molecules ; 26(16)2021 Aug 18.
Article in English | MEDLINE | ID: covidwho-1360793

ABSTRACT

The thrombotic thrombocytopenia syndrome (TTS), a complication of COVID-19 vaccines, involves thrombosis (often cerebral venous sinus thrombosis) and thrombocytopenia with occasional pulmonary embolism and arterial ischemia. TTS appears to mostly affect females aged between 20 and 50 years old, with no predisposing risk factors conclusively identified so far. Cases are characterized by thrombocytopenia, higher levels of D-dimers than commonly observed in venous thromboembolic events, inexplicably low fibrinogen levels and worsening thrombosis. Hyper fibrinolysis associated with bleeding can also occur. Antibodies that bind platelet factor 4, similar to those associated with heparin-induced thrombocytopenia, have also been identified but in the absence of patient exposure to heparin treatment. A number of countries have now suspended the use of adenovirus-vectored vaccines for younger individuals. The prevailing opinion of most experts is that the risk of developing COVID-19 disease, including thrombosis, far exceeds the extremely low risk of TTS associated with highly efficacious vaccines. Mass vaccination should continue but with caution. Vaccines that are more likely to cause TTS (e.g., Vaxzevria manufactured by AstraZeneca) should be avoided in younger patients for whom an alternative vaccine is available.


Subject(s)
COVID-19 Vaccines/adverse effects , Thrombocytopenia/chemically induced , Thrombocytopenia/therapy , Thrombosis/chemically induced , Thrombosis/therapy , Antibodies/blood , Diagnosis, Differential , Heparin/adverse effects , Humans , Platelet Factor 4/blood , Thrombocytopenia/etiology , Thrombosis/etiology
6.
Angiogenesis ; 24(4): 755-788, 2021 11.
Article in English | MEDLINE | ID: covidwho-1286153

ABSTRACT

Coronavirus disease 2019 (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is presenting as a systemic disease associated with vascular inflammation and endothelial injury. Severe forms of SARS-CoV-2 infection induce acute respiratory distress syndrome (ARDS) and there is still an ongoing debate on whether COVID-19 ARDS and its perfusion defect differs from ARDS induced by other causes. Beside pro-inflammatory cytokines (such as interleukin-1 ß [IL-1ß] or IL-6), several main pathological phenomena have been seen because of endothelial cell (EC) dysfunction: hypercoagulation reflected by fibrin degradation products called D-dimers, micro- and macrothrombosis and pathological angiogenesis. Direct endothelial infection by SARS-CoV-2 is not likely to occur and ACE-2 expression by EC is a matter of debate. Indeed, endothelial damage reported in severely ill patients with COVID-19 could be more likely secondary to infection of neighboring cells and/or a consequence of inflammation. Endotheliopathy could give rise to hypercoagulation by alteration in the levels of different factors such as von Willebrand factor. Other than thrombotic events, pathological angiogenesis is among the recent findings. Overexpression of different proangiogenic factors such as vascular endothelial growth factor (VEGF), basic fibroblast growth factor (FGF-2) or placental growth factors (PlGF) have been found in plasma or lung biopsies of COVID-19 patients. Finally, SARS-CoV-2 infection induces an emergency myelopoiesis associated to deregulated immunity and mobilization of endothelial progenitor cells, leading to features of acquired hematological malignancies or cardiovascular disease, which are discussed in this review. Altogether, this review will try to elucidate the pathophysiology of thrombotic complications, pathological angiogenesis and EC dysfunction, allowing better insight in new targets and antithrombotic protocols to better address vascular system dysfunction. Since treating SARS-CoV-2 infection and its potential long-term effects involves targeting the vascular compartment and/or mobilization of immature immune cells, we propose to define COVID-19 and its complications as a systemic vascular acquired hemopathy.


Subject(s)
COVID-19/metabolism , Myelopoiesis , Neovascularization, Pathologic/metabolism , Respiratory Distress Syndrome/metabolism , SARS-CoV-2/metabolism , Thrombosis/metabolism , COVID-19/pathology , COVID-19/therapy , Endothelial Cells/metabolism , Endothelial Cells/pathology , Endothelial Cells/virology , Fibrin Fibrinogen Degradation Products/metabolism , Fibroblast Growth Factor 2/metabolism , Humans , Interleukin-1beta/metabolism , Interleukin-6/metabolism , Membrane Proteins/metabolism , Neovascularization, Pathologic/pathology , Neovascularization, Pathologic/therapy , Neovascularization, Pathologic/virology , Respiratory Distress Syndrome/pathology , Respiratory Distress Syndrome/therapy , Respiratory Distress Syndrome/virology , Thrombosis/pathology , Thrombosis/therapy , Thrombosis/virology , Vascular Endothelial Growth Factor A/metabolism , von Willebrand Factor/metabolism
7.
Br J Haematol ; 194(3): 518-529, 2021 08.
Article in English | MEDLINE | ID: covidwho-1266318

ABSTRACT

The COVID-19 pandemic has been the most significant health crisis in recent global history. Early studies from Wuhan highlighted COVID-19-associated coagulopathy and a significant association with mortality was soon recognised. As research continues across the world, more evidence is emerging of the cross-talk between the innate immune system, coagulation activation and inflammation. Immunothrombosis has been demonstrated to play a key role in the pathophysiology of severe COVID-19, with extracellular histones and neutrophil extracellular traps detected in the plasma and cardiopulmonary tissues of critically ill patients. Targeting the components of immunothrombosis is becoming an important factor in the treatment of patients with COVID-19 infection. Recent studies report outcomes of intermediate and therapeutic anticoagulation in hospitalised patients with varying severities of COVID-19 disease, including optimal dosing and associated bleeding risks. Immunomodulatory therapies, including corticosteroids and IL-6 receptor antagonists, have been demonstrated to significantly reduce mortality in COVID-19 patients. As the pandemic continues, more studies are required to understand the driving factors and upstream mechanisms for coagulopathy and immunothrombosis in COVID-19, and thus potentially develop more targeted therapies for SARS-CoV-2 infection, both in the acute phase and in those who develop longer-term symptom burden.


Subject(s)
COVID-19/complications , Thrombosis/etiology , Animals , Blood Coagulation , COVID-19/blood , COVID-19/immunology , COVID-19/therapy , Disease Management , Humans , Immunogenic Cell Death , Inflammation/blood , Inflammation/etiology , Inflammation/immunology , Inflammation/therapy , SARS-CoV-2/immunology , Thrombosis/blood , Thrombosis/immunology , Thrombosis/therapy
8.
J Thromb Thrombolysis ; 52(3): 746-753, 2021 Oct.
Article in English | MEDLINE | ID: covidwho-1263169

ABSTRACT

Patients with Coronavirus Disease-2019 (COVID-19) have haemostatic dysfunction and are at higher risk of thrombotic complications. Although age is a major risk factor for outcome impairment in COVID-19, its impact on coagulative patterns here is still unclear. We investigated the association of Endogenous Thrombin Potential (ETP) with thrombotic and haemorrhagic events according to different ages in patients admitted for COVID-19. A total of 27 patients with COVID-19-related pneumonia, without need for intensive care unit admission or mechanical ventilation at hospital presentation, and 24 controls with non-COVID-19 pneumonia were prospectively included. ETP levels were measured on admission. Patients were evaluated for major adverse cardiovascular events (MACE: cardiovascular death, myocardial infarction, stroke, transient ischemic attack, venous thromboembolism) and bleeding complications [according to Bleeding Academic Research Consortium (BARC) definition] during in-hospital stay. COVID-19 patients had similar ETP levels compared to controls (AUC 93 ± 24% vs 99 ± 21%, p = 0.339). In the COVID-19 cohort, patients with in-hospital MACE showed lower ETP levels on admission vs those without (AUC 86 ± 14% vs 95 ± 27%, p = 0.041), whereas ETP values were comparable in patients with or without bleeding (AUC 82 ± 16% vs 95 ± 26%, p = 0.337). An interaction between age and ETP levels for both MACE and bleeding complications was observed, where a younger age was associated with an inverse relationship between ETP values and adverse event risk (pint 0.018 for MACE and 0.050 for bleeding). Patients with COVID-19 have similar thrombin potential on admission compared to those with non-COVID-19 pneumonia. In younger COVID-19 patients, lower ETP levels were associated with a higher risk of both MACE and bleeding.


Subject(s)
COVID-19/complications , Hemostasis , Hospitalization , Thrombin/metabolism , Thrombosis/etiology , Age Factors , Aged , Aged, 80 and over , Biomarkers/blood , COVID-19/blood , COVID-19/mortality , COVID-19/therapy , Case-Control Studies , Female , Humans , Male , Middle Aged , Prognosis , Prospective Studies , Risk Assessment , Risk Factors , Thrombosis/blood , Thrombosis/mortality , Thrombosis/therapy , Time Factors
9.
N Engl J Med ; 385(8): 720-728, 2021 08 19.
Article in English | MEDLINE | ID: covidwho-1262030

ABSTRACT

The use of high-dose intravenous immune globulin (IVIG) plus anticoagulation is recommended for the treatment of vaccine-induced immune thrombotic thrombocytopenia (VITT), a rare side effect of adenoviral vector vaccines against coronavirus disease 2019 (Covid-19). We describe the response to IVIG therapy in three of the first patients in whom VITT was identified in Canada after the receipt of the ChAdOx1 nCoV-19 vaccine. The patients were between the ages of 63 and 72 years; one was female. At the time of this report, Canada had restricted the use of the ChAdOx1 nCoV-19 vaccine to persons who were 55 years of age or older on the basis of reports that VITT had occurred primarily in younger persons. Two of the patients in our study presented with limb-artery thrombosis; the third had cerebral venous and arterial thrombosis. Variable patterns of serum-induced platelet activation were observed in response to heparin and platelet factor 4 (PF4), indicating the heterogeneity of the manifestations of VITT in serum. After the initiation of IVIG, reduced antibody-induced platelet activation in serum was seen in all three patients. (Funded by the Canadian Institutes of Health Research.).


Subject(s)
COVID-19 Vaccines/adverse effects , Immunoglobulins, Intravenous , Thrombocytopenia/therapy , Thrombosis/therapy , Aged , Female , Fibrin Fibrinogen Degradation Products/analysis , Fibrinogen/analysis , Heparin/pharmacology , Humans , Male , Middle Aged , Platelet Count , Platelet Factor 4/pharmacology , Serotonin/blood , Thrombocytopenia/blood , Thrombocytopenia/etiology , Thrombosis/etiology , Thrombosis/immunology
12.
Semin Vasc Surg ; 34(2): 8-12, 2021 Jun.
Article in English | MEDLINE | ID: covidwho-1240793

ABSTRACT

This literature review discusses the current evidence on acute limb ischemia (ALI) in patients with COVID-19. Throughout the pandemic, these patients have been at increased risk of arterial thrombotic events and subsequent mortality as a result of a hypercoagulable state. The exact mechanism of thrombosis is unknown; however arterial thrombosis may be due to invasion of endothelial cells via angiotensin-converting enzyme 2 (ACE2) receptors, endothelial injury from inflammation, or even free-floating aortic thrombus. Multiple studies have been performed evaluating the medical and surgical management of these patients; the decision to proceed with operative intervention is dependent on the patient's clinical status as it relates to COVID-19 and morbidity of that disease. The interventions afforded typically include anticoagulation in patients undergoing palliation; alternatively, thrombectomy (endovascular and open) is utilized in other patients. There is a high risk of rethrombosis, despite anticoagulation, given persistent endothelial injury from the virus. Postoperative mortality can be high in these patients.


Subject(s)
COVID-19/complications , Ischemia/therapy , Ischemia/virology , Lower Extremity/blood supply , Thrombosis/therapy , Thrombosis/virology , Anticoagulants/therapeutic use , COVID-19/diagnosis , COVID-19/therapy , Humans , Ischemia/diagnosis , Thrombectomy , Thrombosis/diagnosis
13.
Am J Pathol ; 191(8): 1374-1384, 2021 08.
Article in English | MEDLINE | ID: covidwho-1240148

ABSTRACT

Patients with coronavirus disease 2019 (COVID-19) who are critically ill develop vascular complications characterized by thrombosis of small, medium, and large vessels. Dysfunction of the vascular endothelium due to the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has been implicated in the pathogenesis of the COVID-19 vasculopathy. Although initial reports suggested that endothelial injury was caused directly by the virus, recent studies indicate that endothelial cells do not express angiotensin-converting enzyme 2, the receptor that SARS-CoV-2 uses to gain entry into cells, or express it at low levels and are resistant to the infection. These new findings, together with the observation that COVID-19 triggers a cytokine storm capable of injuring the endothelium and disrupting its antithrombogenic properties, favor an indirect mechanism of endothelial injury mediated locally by an augmented inflammatory reaction to infected nonendothelial cells, such as the bronchial and alveolar epithelium, and systemically by the excessive immune response to infection. Herein we review the vascular pathology of COVID-19 and critically discuss the potential mechanisms of endothelial injury in this disease.


Subject(s)
COVID-19/metabolism , Cytokine Release Syndrome/metabolism , Endothelium, Vascular/injuries , Endothelium, Vascular/metabolism , SARS-CoV-2/metabolism , Thrombosis/metabolism , Angiotensin-Converting Enzyme 2/metabolism , Bronchi/metabolism , Bronchi/pathology , COVID-19/complications , COVID-19/pathology , COVID-19/therapy , Cytokine Release Syndrome/etiology , Cytokine Release Syndrome/pathology , Cytokine Release Syndrome/therapy , Endothelium, Vascular/pathology , Humans , Pulmonary Alveoli/metabolism , Pulmonary Alveoli/pathology , Respiratory Mucosa/metabolism , Respiratory Mucosa/pathology , Thrombosis/etiology , Thrombosis/pathology , Thrombosis/therapy
14.
Eur J Haematol ; 107(2): 173-180, 2021 Aug.
Article in English | MEDLINE | ID: covidwho-1228750

ABSTRACT

Very rare cases of thrombosis associated with thrombocytopenia have occurred following the vaccination with AstraZeneca COVID-19 vaccine. The aim of this concise review is to summarize the current knowledge on the epidemiologic and pathogenic mechanisms of this syndrome named vaccine-associated immune thrombosis and thrombocytopenia (VITT). A practical patient management section will also be dealt with using information available from national and international scientific societies as well as expert panels. A literature search on the VITT syndrome was carried out in PubMed using appropriate MeSH headings. Overall, 40 VITT cases have been reported. Continuous pharmacovigilance monitoring is needed to collect more data on the real incidence and the pathogenesis of VITT syndrome. Such information will also help us to optimize the management this rare but often clinically severe thrombotic condition associated with COVID-19 vaccination.


Subject(s)
COVID-19 Vaccines/adverse effects , COVID-19/complications , SARS-CoV-2 , Thrombocytopenia/etiology , Thrombosis/etiology , Biomarkers , COVID-19/epidemiology , COVID-19/prevention & control , COVID-19 Vaccines/administration & dosage , COVID-19 Vaccines/immunology , Cost of Illness , Disease Management , Disease Susceptibility , Humans , Patient Outcome Assessment , Risk Assessment , Risk Factors , SARS-CoV-2/immunology , Severity of Illness Index , Syndrome , Thrombocytopenia/diagnosis , Thrombocytopenia/epidemiology , Thrombocytopenia/therapy , Thrombosis/diagnosis , Thrombosis/epidemiology , Thrombosis/therapy
15.
Ideggyogy Sz ; 74(3-4): 129-134, 2021 Mar 30.
Article in Hungarian | MEDLINE | ID: covidwho-1212100

ABSTRACT

In SARS-CoV-2 positive patients with corresponding neurological symptoms the presence of carotid bifurcation macrothrombus should always be considered. Hypercoagulopathy caused by viral endotheliitis, systemic inflammation and cytokine storm play an important role in its development. Here we present two patients treated with different treatment strategies because of carotid bifurcation macrothrombus as a complication of SARS-CoV-2 infection. In both cases, the soft macrothrombus was eliminated and the patients' neurological condition were improved. Intravenous thrombolysis, acute carotid stenting with embolic filter protection device and mechanical thrombectomy with aspiration are effective treatments.


Subject(s)
COVID-19 , Stroke , Thrombosis , Humans , SARS-CoV-2 , Stents , Thrombectomy , Thrombosis/diagnostic imaging , Thrombosis/etiology , Thrombosis/therapy , Treatment Outcome
16.
Vasc Endovascular Surg ; 55(7): 781-786, 2021 Oct.
Article in English | MEDLINE | ID: covidwho-1181066

ABSTRACT

The optimal management strategy of acute limb ischemia in non-ventilated patients with COVID-19 is uncertain. We propose that non-ventilated patients who develop COVID-19 related spontaneous arterial thrombosis with associated limb threat may be best suited with percutnaeous revascularization to achieve limb salvage. Herein we describe 5 cases of patients who had severely threatened limbs with complete thrombosis of all 3 tibial arteries who were treated with percutaneous revascularization. All 5 patients were felt to be facing inevitable amputation without revascularization should they survive their COVID hospitalization. We were able to achieve limb salvage in all 5 patients selected for therapy, although 2 ultimately succumbed to respiratory failure.


Subject(s)
Angioplasty, Balloon , Arterial Occlusive Diseases/therapy , COVID-19/complications , Ischemia/therapy , Thrombectomy , Thrombolytic Therapy , Thrombosis/therapy , Aged , Amputation , Arterial Occlusive Diseases/diagnostic imaging , Arterial Occlusive Diseases/etiology , COVID-19/diagnosis , Fatal Outcome , Humans , Ischemia/diagnostic imaging , Ischemia/etiology , Limb Salvage , Male , Middle Aged , Thrombosis/diagnostic imaging , Thrombosis/etiology , Treatment Outcome
17.
J Thromb Thrombolysis ; 52(3): 974-979, 2021 Oct.
Article in English | MEDLINE | ID: covidwho-1163124

ABSTRACT

Coronavirus disease 2019 (COVID-19) has emerged as a pandemic across the world. Hypercoagulability status in COVID-19 is one of the causes of complication from severe COVID-19 with a high risk of arterial thrombosis. Acute Limb Ischemia is a vascular emergency caused by sudden decrease in the arterial perfusion. We report the case of a 53-year-old male patient with COVID-19 Pneumonia, diagnosed with Acute Limb Ischemia. From clinical examination, which included anamnesis, physical examination, and laboratory results as well as chest X-rays, a suspicion of Acute Limb Ischemia was found in a patient with COVID-19 pneumonia. The SARS-CoV-2 real time PCR examination showed positive results. In this patient, the diagnosis of Acute Limb Ischemia with Covid-19 Pneumonia was established through a multidisciplinary approach covering the fields of pulmonology, cardiology, and thoracic and cardiovascular surgery.


Subject(s)
COVID-19/complications , Ischemia/etiology , Lower Extremity/blood supply , Peripheral Arterial Disease/etiology , Thrombosis/etiology , Acute Disease , Anticoagulants/therapeutic use , COVID-19/diagnosis , COVID-19/therapy , Fibrinolytic Agents/therapeutic use , Humans , Ischemia/diagnosis , Ischemia/therapy , Male , Middle Aged , Peripheral Arterial Disease/diagnosis , Peripheral Arterial Disease/therapy , Thrombectomy , Thrombosis/diagnosis , Thrombosis/therapy , Treatment Outcome
18.
Homeopathy ; 110(2): 132-136, 2021 05.
Article in English | MEDLINE | ID: covidwho-1093379

ABSTRACT

Thromboinflammation is a still not well-understood phenomenon, which has recently come to the foreground as a function of its relevance in the pathophysiology of coronavirus disease 2019 (COVID-19). The patient described in the present case report exhibited acute fever, giant urticaria, elevated acute phase reactants, and very high d-dimer levels, thus characterizing thromboinflammation. She was diagnosed as a COVID-19 suspect case, which was not confirmed; urticarial vasculitis was ruled out. Homeopathic treatment was started with the earliest clinical manifestations, resulting in rapid and drastic reduction of inflammation and hypercoagulability within the first 12 hours, and full recovery on 10-day follow-up assessment. This case demonstrates the effectiveness of homeopathy in a severe acute disorder, and points to the need to include laboratory testing in homeopathic clinical assessment to achieve an accurate picture of disease, and to avoid the risk of passing over life-threatening disorders.


Subject(s)
Bee Venoms/therapeutic use , Bees , COVID-19/complications , Homeopathy , Inflammation/therapy , Thrombosis/therapy , Aged , Animals , C-Reactive Protein/analysis , Female , Fever/virology , Fibrin Fibrinogen Degradation Products/analysis , Humans , Inflammation/virology , Thrombosis/virology , Urticaria/virology
19.
An Sist Sanit Navar ; 43(2): 245-249, 2020 Aug 31.
Article in Spanish | MEDLINE | ID: covidwho-1083299

ABSTRACT

One of the most significant negative prognostic factors in patients suffering from the disease caused by SARS-CoV-2 (COVID-19) is the development of coagulopathy, associated with abnormal laboratory findings, such as increased D-dimer, and venous thromboembolic complications, requiring thromboprophylactic strategies. The main clinical characteristics of COVID-19 patients are revised here as compared to other coronavirus infections, such as Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS), emphasizing clinical, diagnostic and therapeutic aspects.


Subject(s)
Betacoronavirus , Blood Coagulation Disorders/virology , Coronavirus Infections/diagnosis , Middle East Respiratory Syndrome Coronavirus , SARS Virus , Thrombosis/virology , Blood Coagulation Disorders/diagnosis , Blood Coagulation Disorders/therapy , COVID-19 , Coronavirus Infections/complications , Coronavirus Infections/physiopathology , Coronavirus Infections/therapy , Fibrinolytic Agents/therapeutic use , Humans , Pandemics , Pneumonia, Viral/complications , Pneumonia, Viral/diagnosis , Pneumonia, Viral/physiopathology , Pneumonia, Viral/therapy , Prognosis , SARS-CoV-2 , Severe Acute Respiratory Syndrome/complications , Severe Acute Respiratory Syndrome/diagnosis , Severe Acute Respiratory Syndrome/physiopathology , Severe Acute Respiratory Syndrome/therapy , Thrombosis/diagnosis , Thrombosis/therapy
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