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1.
J Vasc Surg Venous Lymphat Disord ; 9(3): 605-614.e2, 2021 05.
Article in English | MEDLINE | ID: covidwho-1510080

ABSTRACT

OBJECTIVE: Early reports suggest that patients with novel coronavirus disease-2019 (COVID-19) infection carry a significant risk of altered coagulation with an increased risk for venous thromboembolic events. This report investigates the relationship of significant COVID-19 infection and deep venous thrombosis (DVT) as reflected in the patient clinical and laboratory characteristics. METHODS: We reviewed the demographics, clinical presentation, laboratory and radiologic evaluations, results of venous duplex imaging and mortality of COVID-19-positive patients (18-89 years) admitted to the Indiana University Academic Health Center. Using oxygen saturation, radiologic findings, and need for advanced respiratory therapies, patients were classified into mild, moderate, or severe categories of COVID-19 infection. A descriptive analysis was performed using univariate and bivariate Fisher's exact and Wilcoxon rank-sum tests to examine the distribution of patient characteristics and compare the DVT outcomes. A multivariable logistic regression model was used to estimate the adjusted odds ratio of experiencing DVT and a receiver operating curve analysis to identify the optimal cutoff for d-dimer to predict DVT in this COVID-19 cohort. Time to the diagnosis of DVT from admission was analyzed using log-rank test and Kaplan-Meier plots. RESULTS: Our study included 71 unique COVID-19-positive patients (mean age, 61 years) categorized as having 3% mild, 14% moderate, and 83% severe infection and evaluated with 107 venous duplex studies. DVT was identified in 47.8% of patients (37% of examinations) at an average of 5.9 days after admission. Patients with DVT were predominantly male (67%; P = .032) with proximal venous involvement (29% upper and 39% in the lower extremities with 55% of the latter demonstrating bilateral involvement). Patients with DVT had a significantly higher mean d-dimer of 5447 ± 7032 ng/mL (P = .0101), and alkaline phosphatase of 110 IU/L (P = .0095) than those without DVT. On multivariable analysis, elevated d-dimer (P = .038) and alkaline phosphatase (P = .021) were associated with risk for DVT, whereas age, sex, elevated C-reactive protein, and ferritin levels were not. A receiver operating curve analysis suggests an optimal d-dimer value of 2450 ng/mL cutoff with 70% sensitivity, 59.5% specificity, and 61% positive predictive value, and 68.8% negative predictive value. CONCLUSIONS: This study suggests that males with severe COVID-19 infection requiring hospitalization are at highest risk for developing DVT. Elevated d-dimers and alkaline phosphatase along with our multivariable model can alert the clinician to the increased risk of DVT requiring early evaluation and aggressive treatment.


Subject(s)
Alkaline Phosphatase/blood , COVID-19 , Extremities , Fibrin Fibrinogen Degradation Products/analysis , Risk Assessment/methods , Ultrasonography, Doppler, Duplex , Venous Thrombosis , Anticoagulants/administration & dosage , Biomarkers/blood , Blood Coagulation , COVID-19/blood , COVID-19/complications , COVID-19/mortality , COVID-19/therapy , Early Diagnosis , Extremities/blood supply , Extremities/diagnostic imaging , Female , Humans , Indiana/epidemiology , Male , Middle Aged , Predictive Value of Tests , Retrospective Studies , SARS-CoV-2/isolation & purification , Time-to-Treatment/statistics & numerical data , Ultrasonography, Doppler, Duplex/methods , Ultrasonography, Doppler, Duplex/statistics & numerical data , Venous Thrombosis/diagnosis , Venous Thrombosis/drug therapy , Venous Thrombosis/etiology , Venous Thrombosis/prevention & control
2.
Medicine (Baltimore) ; 100(38): e27216, 2021 Sep 24.
Article in English | MEDLINE | ID: covidwho-1437853

ABSTRACT

ABSTRACT: Deep venous thrombosis (DVT) is associated with high mortality in coronavirus disease 2019 (COVID-19) but there remains uncertainty about the benefit of anti-coagulation prophylaxis and how to decide when ultrasound screening is indicated. We aimed to determine parameters predicting which COVID-19 patients are at risk of DVT and to assess the benefit of prophylactic anti-coagulation.Adult hospitalized patients with positive severe acute respiratory syndrome coronavirus-2 reverse transcription-polymerase chain reaction (RT-PCR) undergoing venous duplex ultrasound for DVT assessment (n = 451) were retrospectively reviewed. Clinical and laboratory data within 72 hours of ultrasound were collected. Using split sampling and a 10-fold cross-validation, a random forest model was developed to find the most important variables for predicting DVT. Different d-dimer cutoffs were examined for classification of DVT. We also compared the rate of DVT between the patients going and not going under thromboprophylaxis.DVT was found in 65 (14%) of 451 reverse transcription-polymerase chain reaction positive patients. The random forest model, trained and cross-validated on 2/3 of the original sample (n = 301), had area under the receiver operating characteristic curve = 0.91 (95% confidence interval [CI]: 0.85-0.97) for prediction of DVT in the test set (n = 150), with sensitivity = 93% (95%CI: 68%-99%) and specificity = 82% (95%CI: 75%-88%). The following variables had the highest importance: d-dimer, thromboprophylaxis, systolic blood pressure, admission to ultrasound interval, and platelets. Thromboprophylaxis reduced DVT risk 4-fold from 26% to 6% (P < .001), while anti-coagulation therapy led to hemorrhagic complications in 14 (22%) of 65 patients with DVT including 2 fatal intra-cranial hemorrhages. D-dimer was the most important predictor with area under curve = 0.79 (95%CI: 0.73-0.86) by itself, and a 5000 ng/mL threshold at 7 days postCOVID-19 symptom onset had 75% (95%CI: 53%-90%) sensitivity and 81% (95%CI: 72%-88%) specificity. In comparison with d-dimer alone, the random forest model showed 68% versus 32% specificity at 95% sensitivity, and 44% versus 23% sensitivity at 95% specificity.D-dimer >5000 ng/mL predicts DVT with high accuracy suggesting regular monitoring with d-dimer in the early stages of COVID-19 may be useful. A random forest model improved the prediction of DVT. Thromboprophylaxis reduced DVT in COVID-19 patients and should be considered in all patients. Full anti-coagulation therapy has a risk of life-threatening hemorrhage.


Subject(s)
Anticoagulants/adverse effects , COVID-19/complications , Fibrin Fibrinogen Degradation Products/analysis , Ultrasonography, Doppler, Duplex/standards , Venous Thrombosis/etiology , Venous Thrombosis/prevention & control , Acute Disease , Aged , Aged, 80 and over , Anticoagulants/therapeutic use , COVID-19/diagnosis , COVID-19/epidemiology , COVID-19/virology , COVID-19 Nucleic Acid Testing/methods , Case-Control Studies , Female , Hospitalization/statistics & numerical data , Humans , Male , Middle Aged , Predictive Value of Tests , Prevalence , ROC Curve , Retrospective Studies , Risk Factors , SARS-CoV-2/genetics , Sensitivity and Specificity , Ultrasonography, Doppler, Duplex/methods , Venous Thrombosis/epidemiology , Venous Thrombosis/mortality
3.
Ultrasound Q ; 37(3): 254-260, 2021 Sep 01.
Article in English | MEDLINE | ID: covidwho-1393538

ABSTRACT

ABSTRACT: This retrospective study shares our departmental experience of screening of ultrasound (US) requests, triaging of studies, and abbreviated US protocols implemented during the COVID-19 pandemic. For US studies requested in April and May 2020, the following data were collected: type of study, indication, COVID-19 status (positive or patient under investigation [PUI]), decision to perform study, US findings, and location of patient. A total of 196 US studies in 150 patients were included. The median age of patients was 60 years (female: 46.7% [70/150]). At the time of study request, 83 patients (55.3%) were COVID-19-positive and 67 (44.7%) were PUI, of which 8 (11.9%) tested positive after waiting for test result. The most frequently requested study was venous extremity Doppler (51%), followed by right upper quadrant (20.4%), renal (11.7%), and liver duplex (6.6%). After radiologist screening and triage of US requests, 156 studies were performed (79.6%), 15 were postponed until COVID test result (7.6%), and 40 were not performed after discussion with ordering provider (20.4%). Notably, 40.1% of studies performed on COVID-19-positive patients yielded pathological findings, most frequently deep venous thrombosis (18.1%), medical renal disease (7.6%), and gall bladder sludge (5.7%). Abbreviated US protocols were used in 29.4% of studies. In conclusion, US study screening and triage played an important role to optimize care of COVID-19 patients and PUIs.


Subject(s)
COVID-19/epidemiology , Pandemics , SARS-CoV-2 , Tertiary Care Centers/statistics & numerical data , Ultrasonography, Doppler, Duplex/methods , Venous Thrombosis/diagnosis , Adult , COVID-19/complications , Female , Humans , Male , Middle Aged , Retrospective Studies , Venous Thrombosis/etiology
4.
J Ultrasound Med ; 41(5): 1095-1100, 2022 May.
Article in English | MEDLINE | ID: covidwho-1338189

ABSTRACT

BACKGROUND: There is growing evidence regarding the venous thromboembolic (VTE) pathophysiology of coronavirus disease 2019 (COVID-19). Several studies have reported varying incidences of this disease. OBJECTIVES: The main purpose of this study was to determine the real incidence of deep or superficial vein thrombosis in COVID-19. The study also aimed to identify risk and protective factors for VTE. METHODS: Patients were consecutively enrolled and assessed with a bilateral Duplex ultrasonography of lower limbs during hospitalization. The exam was repeated weekly until discharge, and then follow-up for 1 month. RESULTS: Two-hundred and thirty-three patients were enrolled. Mean age was 54.4 years (SD 12.7) and 47.8% were female. About 127 patients (54.5%) had comorbidities. At enrollment, patients were normotensive and had normal saturation (95.6%-SD 1.6, with a respiratory rate of 19.1 rpm-SD 4.0), with 130 needing at least supplementary oxygen therapy (55.8%). About 147 patients (63.1%) had at least 1 Duplex ultrasonography study performed and 1.7% had 5 or more studies. One patient had a distal posterior tibial vein thrombosis, which showed signs of chronicity and was congruent with the patient history. Therefore, the incidence of thrombotic events was nearly zero. DISCUSSION: Our study results suggest that performing a Duplex Ultrasonography screening protocol in stable COVID-19 patient populations, who may need hospitalization but are without symptoms of vein thrombosis, is not founded. We presumably emphasize the advantage of using intermediate LMWH doses as well as early walking in COVID-19 patients.


Subject(s)
COVID-19 , Venous Thromboembolism , Venous Thrombosis , COVID-19/complications , Female , Heparin, Low-Molecular-Weight , Humans , Male , Middle Aged , Retrospective Studies , Ultrasonography, Doppler, Duplex/methods , Venous Thrombosis/complications , Venous Thrombosis/diagnostic imaging
5.
Emerg Radiol ; 28(3): 469-476, 2021 Jun.
Article in English | MEDLINE | ID: covidwho-1018361

ABSTRACT

OBJECTIVE: To investigate the incidence of thromboembolic events, specifically pulmonary embolism (PE), deep vein thrombosis (DVT), and cerebrovascular accidents (CVA), in patients who tested positive for COVID-19 through RT-PCR in a regional healthcare system in Connecticut. MATERIALS AND METHODS: All CT angiogram (CTA) and venous duplex extremity ultrasound (US) examinations performed on 192 consecutively documented cases of COVID-19 were retrospectively reviewed at a multi-centered healthcare system. Clinical characteristics and patient outcomes were evaluated and compared between two groups based on the presence or absence of acute thromboembolic events. RESULTS: Of the 16,264 patients tested for COVID-19, 3727 (23%) were positive. Out of those, 192 patients underwent 245 vascular imaging studies including chest CTA (86), venous duplex ultrasound (134), and CTA head and neck (25). Among those who underwent imaging, 49 (26%) demonstrated acute thromboembolic events which included 13/86 (15%) with PE, 34/134 (25%) with DVT, and 6/25 (24%) with CVA. One patient had positive results on all 3 examinations, and 2 patients had positive results on both chest CTA and venous duplex US. Males were more likely to have a thromboembolic event than females (33/103 (34%) vs. 14/89 (16%), p = 0.009). No significant difference was observed with respect to age, cardiopulmonary comorbidities, malignancy history, diabetes, or dialysis. CONCLUSION: Approximately 26% of COVID-19 patients with positive testing who underwent vascular imaging with CTA or venous duplex ultrasound had thromboembolic events including PE, DVT, and CVA. This indicates that COVID-19 patients are at increased risk for thromboembolic complications.


Subject(s)
COVID-19/complications , Computed Tomography Angiography/methods , Thromboembolism/diagnostic imaging , Thromboembolism/virology , Ultrasonography, Doppler, Duplex/methods , Aged , COVID-19/epidemiology , Connecticut/epidemiology , Female , Humans , Male , Middle Aged , Retrospective Studies , SARS-CoV-2 , Thromboembolism/epidemiology
6.
J Vasc Surg Venous Lymphat Disord ; 9(3): 597-604, 2021 05.
Article in English | MEDLINE | ID: covidwho-905174

ABSTRACT

OBJECTIVE: The pandemic of coronavirus disease 2019 (COVID-19) has caused devastating morbidity and mortality worldwide. In particular, thromboembolic complications have emerged as a key threat for patients with COVID-19. We assessed our experience with deep vein thrombosis (DVT) in patients with COVID-19. METHODS: We performed a retrospective analysis of all patients with COVID-19 who had undergone upper or lower extremity venous duplex ultrasonography at an academic health system in New York City from March 3, 2020 to April 12, 2020 with follow-up through May 12, 2020. A cohort of hospitalized patients without COVID-19 (non-COVID-19) who had undergone venous duplex ultrasonography from December 1, 2019 to December 31, 2019 was used for comparison. The primary outcome was DVT. The secondary outcomes included pulmonary embolism, in-hospital mortality, admission to the intensive care unit, and antithrombotic therapy. Multivariable logistic regression was performed to identify the risk factors for DVT and mortality. RESULTS: Of 443 patients (COVID-19, n = 188; and non-COVID-19, n = 255) who had undergone venous duplex ultrasonography, the COVID-19 cohort had had a greater incidence of DVT (31% vs 19%; P = .005) than had the non-COVID-19 cohort. The incidence of pulmonary embolism was not significantly different statistically between the COVID-19 and non-COVID-19 cohorts (8% vs 4%; P = .105). The DVT location in the COVID-19 group was more often distal (63% vs 29%; P < .001) and bilateral (15% vs 4%; P < .001). The duplex ultrasound findings had a significant impact on the antithrombotic plan; 42 patients (72%) with COVID-19 in the DVT group had their therapy escalated and 49 (38%) and 3 (2%) had their therapy escalated and deescalated in the non-DVT group, respectively (P < .001). Within the COVID-19 cohort, the D-dimer level was significantly greater in the DVT group at admission (2746 ng/mL vs 1481 ng/mL; P = .004) and at the duplex examination (6068 ng/mL vs 3049 ng/mL; P < .01). On multivariable analysis, male sex (odds ratio [OR], 2.27; 95% confidence interval [CI], 1.06-4.87; P = .035), intensive care unit admission (OR, 3.42; 95% CI, 1.02-11.44; P = .046), and extracorporeal membrane oxygenation (OR, 5.5; 95% CI, 1.01-30.13; P = .049) were independently associated with DVT. CONCLUSIONS: Given the high incidence of venous thromboembolic events in this population, we support the decision to empirically initiate therapeutic anticoagulation for patients with a low bleeding risk and severe COVID-19 infection. Duplex ultrasonography should be reserved for patients with a high clinical suspicion of venous thromboembolism for whom anticoagulation therapy could result in life-threatening consequences. Further study of patients with COVID-19 is warranted to elucidate the etiology of vascular thromboembolic events and guide the prophylactic and therapeutic interventions for these patients.


Subject(s)
Anticoagulants/administration & dosage , COVID-19 , Pulmonary Embolism , Risk Adjustment/methods , Ultrasonography, Doppler, Duplex , Venous Thrombosis , COVID-19/blood , COVID-19/complications , COVID-19/epidemiology , Chemoprevention/methods , Extracorporeal Membrane Oxygenation/methods , Female , Fibrin Fibrinogen Degradation Products/analysis , Humans , Intensive Care Units/statistics & numerical data , Male , Middle Aged , New York City/epidemiology , Outcome and Process Assessment, Health Care , Pulmonary Embolism/diagnosis , Pulmonary Embolism/etiology , Pulmonary Embolism/mortality , Pulmonary Embolism/prevention & control , Retrospective Studies , SARS-CoV-2 , Ultrasonography, Doppler, Duplex/methods , Ultrasonography, Doppler, Duplex/statistics & numerical data , Venous Thrombosis/diagnosis , Venous Thrombosis/epidemiology , Venous Thrombosis/etiology , Venous Thrombosis/therapy
7.
J Vasc Surg Venous Lymphat Disord ; 9(3): 585-591.e2, 2021 05.
Article in English | MEDLINE | ID: covidwho-813723

ABSTRACT

BACKGROUND: Infection with the novel severe acute respiratory syndrome coronavirus 2 has been associated with a hypercoagulable state. Emerging data from China and Europe have consistently shown an increased incidence of venous thromboembolism (VTE). We aimed to identify the VTE incidence and early predictors of VTE at our high-volume tertiary care center. METHODS: We performed a retrospective cohort study of 147 patients who had been admitted to Temple University Hospital with coronavirus disease 2019 (COVID-19) from April 1, 2020 to April 27, 2020. We first identified the VTE (pulmonary embolism [PE] and deep vein thrombosis [DVT]) incidence in our cohort. The VTE and no-VTE groups were compared by univariable analysis for demographics, comorbidities, laboratory data, and treatment outcomes. Subsequently, multivariable logistic regression analysis was performed to identify the early predictors of VTE. RESULTS: The 147 patients (20.9% of all admissions) admitted to a designated COVID-19 unit at Temple University Hospital with a high clinical suspicion of acute VTE had undergone testing for VTE using computed tomography pulmonary angiography and/or extremity venous duplex ultrasonography. The overall incidence of VTE was 17% (25 of 147). Of the 25 patients, 16 had had acute PE, 14 had had acute DVT, and 5 had had both PE and DVT. The need for invasive mechanical ventilation (adjusted odds ratio, 3.19; 95% confidence interval, 1.07-9.55) and the admission D-dimer level ≥1500 ng/mL (adjusted odds ratio, 3.55; 95% confidence interval, 1.29-9.78) were independent markers associated with VTE. The all-cause mortality in the VTE group was greater than that in the non-VTE group (48% vs 22%; P = .007). CONCLUSIONS: Our study represents one of the earliest reported from the United States on the incidence rate of VTE in patients with COVID-19. Patients with a high clinical suspicion and the identified risk factors (invasive mechanical ventilation, admission D-dimer level ≥1500 ng/mL) should be considered for early VTE testing. We did not screen all patients admitted for VTE; therefore, the true incidence of VTE could have been underestimated. Our findings require confirmation in future prospective studies.


Subject(s)
COVID-19 , Fibrin Fibrinogen Degradation Products/analysis , Pulmonary Embolism , Respiration, Artificial/methods , Venous Thrombosis , COVID-19/blood , COVID-19/complications , COVID-19/epidemiology , Computed Tomography Angiography/methods , Female , Humans , Incidence , Male , Middle Aged , Philadelphia/epidemiology , Prognosis , Pulmonary Embolism/diagnosis , Pulmonary Embolism/epidemiology , Pulmonary Embolism/etiology , Retrospective Studies , Risk Factors , SARS-CoV-2 , Thrombophilia/blood , Thrombophilia/diagnosis , Thrombophilia/etiology , Ultrasonography, Doppler, Duplex/methods , Venous Thrombosis/diagnosis , Venous Thrombosis/epidemiology , Venous Thrombosis/etiology
8.
J Ultrasound ; 24(2): 165-173, 2021 Jun.
Article in English | MEDLINE | ID: covidwho-718543

ABSTRACT

PURPOSE: Aim of the study is to evaluate the incidence of DVT in COVID-19 patients and its correlation with the severity of the disease and with clinical and laboratory findings. METHODS: 234 symptomatic patients with COVID-19, diagnosed according to the World Health Organization guidelines, were included in the study. The severity of the disease was classified as moderate, severe and critical. Doppler ultrasound (DUS) was performed in all patients. DUS findings, clinical, laboratory's and therapeutic variables were investigated by contingency tables, Pearson chi square test and by Student t test and Fisher's exact test. ROC curve analysis was applied to study significant continuous variables. RESULTS: Overall incidence of DVT was 10.7% (25/234): 1.6% (1/60) among moderate cases, 13.8% (24/174) in severely and critically ill patients. Prolonged bedrest and intensive care unit admission were significantly associated with the presence of DVT (19.7%). Fraction of inspired oxygen, P/F ratio, respiratory rate, heparin administration, D-dimer, IL-6, ferritin and CRP showed correlation with DVT. CONCLUSION: DUS may be considered a useful and valid tool for early identification of DVT. In less severely affected patients, DUS as screening of DVT might be unnecessary. High rate of DVT found in severe patients and its correlation with respiratory parameters and some significant laboratory findings suggests that these can be used as a screening tool for patients who should be getting DUS.


Subject(s)
COVID-19/complications , Ultrasonography, Doppler, Duplex/methods , Venous Thrombosis/complications , Venous Thrombosis/diagnostic imaging , Adult , Aged , C-Reactive Protein/metabolism , Critical Illness , Early Diagnosis , Ferritins/blood , Fibrin Fibrinogen Degradation Products/metabolism , Heparin/administration & dosage , Heparin/blood , Humans , Incidence , Intensive Care Units , Interleukin-6/blood , Male , Middle Aged , Oxygen/metabolism , Respiratory Rate , Risk Assessment , SARS-CoV-2 , Severity of Illness Index , Venous Thrombosis/blood
9.
Ann Vasc Surg ; 68: 83-87, 2020 Oct.
Article in English | MEDLINE | ID: covidwho-640772

ABSTRACT

BACKGROUND: The liability of patients affected by novel coronavirus disease (COVID-19) to develop venous thromboembolic events is widely acknowledged. However, many particulars of the interactions between the two diseases are still unknown. This study aims to outline the main characteristics of deep venous thrombosis (DVT) and pulmonary embolism (PE) in COVID-19 patients, based on the experience of four high-volume COVID-19 hospitals in Northern Italy. METHODS: All cases of COVID-19 in-hospital patients undergoing duplex ultrasound (DUS) for clinically suspected DVT between March 1st and April 25th, 2020, were reviewed. Demographics and clinical data of all patients with confirmed DVT were recorded. Computed tomography pulmonary angiographies of the same population were also examined looking for signs of PE. RESULTS: Of 101 DUS performed, 42 were positive for DVT, 7 for superficial thrombophlebitis, and 24 for PE, 8 of which associated with a DVT. Most had a moderate (43.9%) or mild (16.9%) pneumonia. All venous districts were involved. Time of onset varied greatly, but diagnosis was more frequent in the first two weeks since in-hospital acceptance (73.8%). Most PEs involved the most distal pulmonary vessels, and two-thirds occurred in absence of a recognizable DVT. CONCLUSIONS: DVT, thrombophlebitis, and PE are different aspects of COVID-19 procoagulant activity and they can arise regardless of severity of respiratory impairment. All venous districts can be involved, including the pulmonary arteries, where the high number and distribution of the thrombotic lesions without signs of DVT could hint a primitive thrombosis rather than embolism.


Subject(s)
Betacoronavirus , Coronavirus Infections/complications , Pandemics , Pneumonia, Viral/complications , Ultrasonography, Doppler, Duplex/methods , Venous Thromboembolism/diagnosis , Aged , Aged, 80 and over , COVID-19 , Coronavirus Infections/epidemiology , Female , Humans , Incidence , Italy/epidemiology , Male , Middle Aged , Pneumonia, Viral/epidemiology , Risk Factors , SARS-CoV-2 , Venous Thromboembolism/epidemiology , Venous Thromboembolism/etiology
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