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1.
BMC Infect Dis ; 22(1): 277, 2022 Mar 22.
Article in English | MEDLINE | ID: covidwho-1759707

ABSTRACT

BACKGROUND: Although the RECOVERY trial showed that dexamethasone was efficacious for the treatment of coronavirus disease 2019 (COVID-19), its impact on the risk of pulmonary embolism (PE) and other serious procoagulant events was not assessed. CASE PRESENTATION: Here we report the case of a previously healthy 83-year-old woman with COVID-19, without any genetic predisposition to thrombosis. She developed moderate respiratory distress 12 days after symptom onset and a 10-day course of dexamethasone therapy was initiated. Her clinical condition and imaging findings improved initially; however, they deteriorated after the completion of dexamethasone therapy, despite the improvement in her pneumonia and viral clearance. Laboratory tests showed markedly raised serum D-dimer, ferritin, and sIL-2R levels, and contrast-enhanced computed tomography showed deep vein thrombosis (DVT) in the left iliac vein and PE of the right pulmonary artery. The DVT and PE were successfully treated using intravenous heparin administration. CONCLUSIONS: This case illustrates the potential risk of rebound inflammation and procoagulant events following dexamethasone withdrawal. We believe that COVID-19-induced DVT and PE can be affected by dexamethasone therapy. Although dexamethasone reduces procoagulant factors, increases anticoagulant factors, and modulates cytokines, which can suppress/delay thrombus formation during treatment, it confers the risk for rebound cytokine production after treatment completion, triggering cytokine and coagulation cascades that can lead to thromboembolic diseases. In this critical clinical period, the patient's deteriorating condition may be overlooked because of the masking effects of dexamethasone treatment on fever and other clinical conditions and laboratory changes. Clinicians should follow-up coagulation markers carefully and contrast-enhanced computed tomography is useful for detecting coagulation; and, if PE occurs, therapeutic heparin administration is essential because emboli can also generate cytokines.


Subject(s)
COVID-19 , Pulmonary Embolism , Venous Thrombosis , Aged, 80 and over , COVID-19/complications , COVID-19/drug therapy , Dexamethasone/adverse effects , Female , Humans , Pulmonary Embolism/diagnosis , Pulmonary Embolism/drug therapy , Pulmonary Embolism/etiology , Venous Thrombosis/diagnosis , Venous Thrombosis/drug therapy , Venous Thrombosis/etiology
2.
J Investig Med High Impact Case Rep ; 10: 23247096221084513, 2022.
Article in English | MEDLINE | ID: covidwho-1753092

ABSTRACT

The 2019 coronavirus disease (COVID-19) can present with a wide variety of clinical manifestations, including a hypercoagulable state leading to both arterial and venous thrombosis. Portal vein thrombosis (PVT) in the setting of COVID-19 has rarely been reported in the medical literature. Pylephlebitis with concomitant liver abscess is a rare complication of intra-abdominal infection. Here, we present the case of a 49-year-old man who initially presented with intermittent fevers and generalized weakness of 1-month duration and was subsequently found to have COVID-19 infection, PVT, and Bacteroides fragilis bacteremia with associated pyogenic liver abscess. The patient was treated with intravenous antibiotics and oral anticoagulation with plan to follow up outpatient with gastroenterology in 3 months to ensure resolution of PVT and liver abscess.


Subject(s)
Bacteremia , COVID-19 , Liver Abscess, Pyogenic , Venous Thrombosis , Bacteremia/complications , Bacteremia/drug therapy , Bacteroides , COVID-19/complications , Humans , Liver Abscess, Pyogenic/complications , Liver Abscess, Pyogenic/diagnosis , Liver Abscess, Pyogenic/drug therapy , Male , Middle Aged , Portal Vein , Venous Thrombosis/complications , Venous Thrombosis/drug therapy
3.
Circ J ; 86(3): 458-463, 2022 Feb 25.
Article in English | MEDLINE | ID: covidwho-1714688

ABSTRACT

BACKGROUND: The prevalence of deep venous thrombosis (DVT) among hospitalized psychiatric patients after coronavirus disease 2019 (COVID-19) infection remains unclear.Methods and Results:We retrospectively investigated the prevalence of proximal DVT after COVID-19 infection among 50 hospitalized patients in a Japanese psychiatric hospital that in which a COVID-19 cluster developed between August and September 2020. The prevalence of proximal DVT was 10.0%. Patients with proximal DVT had a lower body weight and higher maximum D-dimer levels and International Medical Prevention Registry on Venous Thromboembolism (IMPROVE) VTE scores. CONCLUSIONS: After COVID-19 infection, hospitalized psychiatric patients are at high risk of DVT and should be carefully followed up.


Subject(s)
COVID-19/complications , Venous Thromboembolism/epidemiology , Venous Thrombosis/epidemiology , Aged , Aged, 80 and over , COVID-19/epidemiology , Female , Hospitals, Psychiatric , Humans , Japan/epidemiology , Male , Prevalence , Retrospective Studies , Risk Factors , SARS-CoV-2 , Venous Thrombosis/drug therapy , Venous Thrombosis/etiology
4.
Semin Thromb Hemost ; 48(3): 309-317, 2022 Apr.
Article in English | MEDLINE | ID: covidwho-1692483

ABSTRACT

Cerebral venous thrombosis (CVT) is a rare form of stroke that often affects younger age groups, especially reproductive age group females. CVT is a potentially fatal neurological condition that can be frequently overlooked due to the vague nature of its clinical and radiological presentation. Headache is the most common presenting symptom. However, a wide range of symptoms can be present and the symptom onset can be acute, subacute, or chronic. Neuroimaging is mandatory in cases where CVT is suspected. Both magnetic resonance venography and computed tomography venography can confirm a diagnosis of CVT. Anticoagulation with low-molecular-weight heparin is the mainstay of treatment. Intracranial hemorrhage is not considered a contraindication to the use of anticoagulants in CVT. Endovascular intervention is still controversial but can be a treatment option for patients with neurological deterioration or thrombus progression, despite the use of anticoagulation or with development of new or worsening intracerebral hemorrhage. Patients with CVT have an increased risk of recurrence of CVT and other types of venous thromboembolism. This review provides an overview of the epidemiology, diagnosis, and treatment of CVT in adults. Commentary about increased presentation of CVT in patients with coronavirus disease 2019 (COVID-19), or after immunization against COVID-19, is also provided.


Subject(s)
COVID-19 , Intracranial Thrombosis , Venous Thrombosis , Adult , Anticoagulants/therapeutic use , Female , Heparin, Low-Molecular-Weight/therapeutic use , Humans , Intracranial Thrombosis/drug therapy , Intracranial Thrombosis/therapy , Venous Thrombosis/drug therapy , Venous Thrombosis/therapy
5.
Medicina (Kaunas) ; 58(2)2022 Feb 02.
Article in English | MEDLINE | ID: covidwho-1667242

ABSTRACT

Background: The frequent occurrence of thromboembolic events in patients infected with the severe acute respiratory syndrome CoV2 (SARS-CoV-2) virus is a well-recognized fact in the medical literature, but less data is available about possible hemorrhagic incidents. Methods: We report the case of a 76-year-old patient who suffered from a mild COVID-19 infection in September 2021 and after four weeks, experienced a completely spontaneous popliteal hematoma followed by deep vein thrombosis (DVT). Therapy with low molecular weight heparins (LMWH) was started, but subsequently, the patient developed a massive sub-pectoral and calf hematoma leading to moderate post-hemorrhagic anemia and acute kidney injury. This patient was treated completely conservatively. Conclusions: Considering the continuous spread of the infection with various, continuously evolving strains of this virus and the extended use of LWMH in clinical practice, such cases were seldom described in the medical literature, but should be considered as a potential cause for hemorrhagic events.


Subject(s)
COVID-19 , Venous Thrombosis , Aged , Hematoma/etiology , Heparin, Low-Molecular-Weight/therapeutic use , Humans , SARS-CoV-2 , Venous Thrombosis/drug therapy , Venous Thrombosis/etiology
6.
J Cardiovasc Surg (Torino) ; 62(6): 548-557, 2021 Dec.
Article in English | MEDLINE | ID: covidwho-1635301

ABSTRACT

INTRODUCTION: We aimed to review the prevalence, the risk factors and the outcomes of venous thrombosis (VT) in patients hospitalized for COronaVirus Disease 19 (COVID-19). EVIDENCE ACQUISITION: Electronic bibliographic databases were searched using the words "COVID venous thrombosis". The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards. EVIDENCE SYNTHESIS: The search of the literature retrieved 877 results. After assessment of full texts, 69 papers were included in the qualitative analysis and 23 of them in the quantitative evaluation. The analyzed studies included a total of 106,838 patients hospitalized for COVID-19 from January to December 2020. The pooled reported prevalence rate of VT was in median 16.7% (IQR 5.8-30%), being higher in ICU patients (60.8-85.4%). VT events were reported in about 75% of cases in the popliteal and calf veins. Signs and symptoms were present in 6.1% of cases. At quantitative evaluation, older age, D-dimer and obesity increased the odds to experience a VT (OR=3.54, 95% CI 0.65-6.43, P=0.01; OR=956.86, 95% CI 225.67-1668.05, P=0.01; OR=1.42, 95% CI 1.01-1.99, P=0.03 respectively). Female sex seemed to be protective against the odds of VT (OR=0.77, 95% CI 0.63-0.93, P=0.007). CONCLUSIONS: Among patients hospitalized for COVID-19, VT is a relatively common finding, with higher prevalence rates in ICU patients. VT occurs mostly in the distal regions of the lower limb and is asymptomatic in most cases. Older age, obesity and higher D-dimer values on admission increased the odds of VT, while female sex was protective against the odds of VT.


Subject(s)
Blood Coagulation , COVID-19/epidemiology , Venous Thrombosis/epidemiology , Age Factors , Anticoagulants/therapeutic use , Biomarkers/blood , Blood Coagulation/drug effects , COVID-19/blood , COVID-19/diagnosis , COVID-19/therapy , Fibrin Fibrinogen Degradation Products/metabolism , Hospitalization , Humans , Obesity/epidemiology , Prevalence , Prognosis , Risk Assessment , Risk Factors , Sex Factors , Venous Thrombosis/blood , Venous Thrombosis/diagnosis , Venous Thrombosis/drug therapy
7.
BMJ Case Rep ; 15(1)2022 Jan 18.
Article in English | MEDLINE | ID: covidwho-1636265

ABSTRACT

Vaccine-induced immune thrombotic thrombocytopenia (VITT) rarely develops after many COVID-19 vaccines. A 51-year-old woman re-presented to hospital with a 4 day history of headache, vomiting, diarrhoea and left calf pain, 11 days after her first dose of ChAdOx1nCoV-19 (AstraZenica) vaccine. Her neurological examination was normal. Blood tests demonstrated a low platelet count, raised D-dimer and CRP, and a positive heparin/anti-PF4 antibody assay. CT venogram demonstrated widespread cerebral venous sinus thrombosis. She was commenced on fondaparinux and intravenous immunoglobulins. The following day she developed an asymmetric quadriplegia and aphasia. CT angiogram demonstrated new bilateral cervical internal carotid artery (ICA) thrombi. She underwent stent-retriever mechanical thrombectomy of bilateral ICA and cerebral venous sinuses. Next day she had right hemiparesis and expressive dysphasia, which are improving. Thromboses due to VITT can progress rapidly to involve cerebral arteries and venous sinuses, and may warrant urgent arterial and venous thrombectomy to reduce morbidity and mortality.


Subject(s)
COVID-19 , Thrombocytopenia , Thrombosis , Venous Thrombosis , COVID-19 Vaccines , Female , Humans , Middle Aged , SARS-CoV-2 , Venous Thrombosis/diagnostic imaging , Venous Thrombosis/drug therapy , Venous Thrombosis/etiology
8.
Vasc Endovascular Surg ; 56(3): 258-262, 2022 Apr.
Article in English | MEDLINE | ID: covidwho-1582580

ABSTRACT

IntroductionPublished evidence of venous thrombotic complications of COVID-19 is lacking from India. This case series consists of twenty-nine adult patients who were COVID -19 positive and treated for Deep Vein Thrombosis (DVT) during the second wave of the COVID-19 pandemic, in India. The study was aimed at analyzing patient demographics of patients with DVT and the outcome of Catheter-Directed Thrombolysis (CDT) in COVID positive patients. Material and Methods: Patients who developed DVT while or after being COVID positive were managed between February and April 2021 at the institution of the first two authors and were included in this retrospective study. Demographic, clinical data, laboratory data, and treatment given were analyzed. All patients were followed up for 3 months with a Villalta score. Results: There were a total of 29 patients (12 male and 17 female) included in the study with a mean age of 47 ± 17 years. The average time of presentation from being COVID positive was 17.8 ± 3.6 days and one patient developed DVT after becoming Covid negative. All but one patient had lower limb involvement, with 42.8% having proximal and 57.2% distal DVT. All patients with Iliofemoral and two with Femoropopliteal DVT were treated with catheter-di thrombolysis and the other 15 patients were managed with anticoagulation alone. No re-thrombosis was observed in the thrombolysis group. Overall average Villalta score at 3 months was 10.7 ± 2.1 with a score of 10.58 ± 2.1 in the anticoagulation-only group and 10.85 ± 2.3 in the CDT group. Conclusion: COVID-19 seems to be an additional risk factor in the development of DVT. The outcome of such patients, treated by thrombolysis appears to be similar to non-COVID patients. In this, observational experience of the authors suggests that CDT could be offered to COVID positive patients with symptomatic Iliofemoral DVT with good outcomes and an acceptable post-intervention Villalta score.


Subject(s)
COVID-19 , Venous Thrombosis , Adult , COVID-19/complications , Catheters , Female , Humans , Iliac Vein , Male , Middle Aged , Pandemics , Retrospective Studies , SARS-CoV-2 , Thrombolytic Therapy/adverse effects , Treatment Outcome , Venous Thrombosis/diagnostic imaging , Venous Thrombosis/drug therapy , Venous Thrombosis/etiology
9.
Int J Environ Res Public Health ; 18(24)2021 12 15.
Article in English | MEDLINE | ID: covidwho-1572481

ABSTRACT

Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is responsible for the coronavirus disease 2019 (COVID-19) pandemic, affecting all age groups with a wide spectrum of clinical presentation ranging from asymptomatic to severe interstitial pneumonia, hyperinflammation, and death. Children and infants generally show a mild course of the disease, although infants have been observed to have a higher risk of hospitalization and severe outcomes. Here, we report the case of a preterm infant with a severe form of SARS-CoV-2 infection complicated by cerebral venous thrombosis successfully treated with steroids, hyperimmune plasma, and remdesivir.


Subject(s)
COVID-19 , Venous Thrombosis , Adenosine Monophosphate/analogs & derivatives , Alanine/analogs & derivatives , COVID-19/drug therapy , Child , Glucocorticoids/therapeutic use , Humans , Infant , Infant, Newborn , Infant, Premature , SARS-CoV-2 , Venous Thrombosis/drug therapy
10.
Dis Markers ; 2021: 4361844, 2021.
Article in English | MEDLINE | ID: covidwho-1523091

ABSTRACT

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is an enveloped RNA virus first identified in December 2019 in Wuhan, China, and responsible for coronavirus disease 2019 (COVID-19). The ongoing COVID-19 pandemic is impacting healthcare worldwide. Patients who develop coagulopathy have worse outcomes. The pathophysiology of COVID-19 suggests a strong interplay between hemostasis and immune cells, especially neutrophils. Our purpose was to assess neutrophil fluorescence as a potential biomarker of deep vein thrombosis (DVT) in patients with COVID-acute respiratory distress syndrome (COVID-ARDS). Sixty-one patients with COVID-ARDS admitted to the four intensive care units (ICUs) of a French general hospital were included in this prospective study. Neutrophil activation was assessed by measuring neutrophil fluorescence (NEUT-Side Fluorescence Light, NEUT-SFL) with a specific fluorescent dye staining analyzed by a routine automated flow cytometer Sysmex XN-3000™ (Sysmex, Kobe, Japan). DVT was diagnosed by complete duplex ultrasound (CDU). We found that NEUT-SFL was elevated on admission in patients with COVID-ARDS (49.76 AU, reference value 46.40 AU, p < 0.001), but did not differ between patients with DVT (49.99 AU) and those without (49.52 AU, p = 0.555). NEUT-SFL is elevated in patients with COVID-ARDS, reflecting neutrophil activation, but cannot be used as a marker of thrombosis. Because neutrophils are at interface between immune response and hemostasis through release of neutrophil extracellular traps, monitoring their activation could be an interesting approach to improve our management of coagulopathy during COVID-ARDS. Further research is needed to better understand the pathophysiology of COVID-19 and identify high-performance biomarkers.


Subject(s)
Biomarkers/blood , COVID-19/complications , Neutrophils/chemistry , Respiratory Distress Syndrome/complications , Venous Thrombosis/blood , Aged , COVID-19/blood , Female , Flow Cytometry/methods , Fluorescence , Humans , Intensive Care Units , Leukocyte Count , Male , Middle Aged , Respiratory Distress Syndrome/virology , Ultrasonography, Doppler, Duplex , Venous Thrombosis/diagnostic imaging , Venous Thrombosis/drug therapy , Venous Thrombosis/virology
11.
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
12.
Zentralbl Chir ; 146(6): 605-611, 2021 Dec.
Article in German | MEDLINE | ID: covidwho-1493282

ABSTRACT

BACKGROUND AND OBJECTIVES: It has been reported that the risk of deep vein thrombosis is greater in patients with COVID-19 infection. We have now investigated whether a standardised therapy can reduce the risk of DVT. MATERIALS AND METHODS: After establishing standard therapy with anticoagulation, steroids and convalescent plasma, we screened 20 patients with COVID-19 pneumonia for DVT by ultrasound examination. The comparison group contained 20 COVID patients with inconsistent therapy, who were examined for the presence of thrombosis during the first wave. RESULTS: In the current patient population with standard therapy, we could not detect any thrombosis, and in the prior patients group only 25% of patients developed DVT. Pulmonary embolism was found in one patient in the first cohort and two in the second. CONCLUSION: The risk of DVT could be reduced through anticoagulation, and administration of steroids and convalescent plasma. The specific significance of the individual components has not yet been clarified. Since bleeding is a rarely observed in SARS-CoV-2 infections, a generous indication for anticoagulation seems to be justified.


Subject(s)
COVID-19 , Pulmonary Embolism , Venous Thrombosis , Anticoagulants/therapeutic use , COVID-19/therapy , Critical Care , Humans , Immunization, Passive , SARS-CoV-2 , Venous Thrombosis/diagnostic imaging , Venous Thrombosis/drug therapy
13.
J Cardiothorac Surg ; 16(1): 226, 2021 Aug 09.
Article in English | MEDLINE | ID: covidwho-1463257

ABSTRACT

BACKGROUND: Inferior vena cava thrombosis is cited to be a complication of inferior vena cava filter placement and post coronary artery bypass surgery. Often only mild symptoms arise from these thrombi; however, due to the chronic nature of some thrombi and the recanalization process, more serious complications can arise. Although anticoagulation remains the gold standard of treatment, some patients are unable to be anticoagulated. In this case, we present a 65-year-old male who underwent IVC filter placement and open-heart surgery who later developed extensive femoral and iliocaval thrombosis leading to right heart failure, which required thrombus extraction with an AngioVac suction device. CASE PRESENTATION: We present a 65-year-old male who presented with bilateral pulmonary emboli with extensive right lower extremity deep vein thrombosis. Upon investigation he had ischemic heart disease and underwent a five-vessel coronary artery bypass for which he had an IVC filter placed preoperatively. On post operative day 3 to 4, he was decompensated and was diagnosed with an IVC thrombus. He progressed to right heart failure and worsening cardiogenic shock despite therapeutic anticoagulation and was taken for a suction thrombectomy using the AngioVac (AngioDynamics, Latham, NY) aspiration thrombectomy device. The thrombectomy was successful and he was able to recover and was discharged from the hospital. CONCLUSION: Despite being a rare complication, IVC thrombosis can have detrimental effects. This case is an example of how IVC thrombus in the post-operative setting can lead to mortality. The gold standard is therapeutic anticoagulation but despite that, this patient continued to have worsening cardiogenic shock. Other therapies have been described but because of its rarity, they are only described in case reports. This case shows that the AngioVac device is a successful treatment option for IVC thrombus and can have the possibility of future use.


Subject(s)
Coronary Artery Bypass/adverse effects , Shock, Cardiogenic/surgery , Thrombectomy , Vena Cava Filters/adverse effects , Vena Cava, Inferior , Venous Thrombosis/surgery , Aged , Anticoagulants/therapeutic use , COVID-19/diagnosis , Coronary Artery Bypass/methods , Heart Failure/drug therapy , Heart Failure/etiology , Heart Failure/surgery , Humans , Male , Pandemics , Prosthesis Implantation/adverse effects , Pulmonary Embolism/drug therapy , Pulmonary Embolism/etiology , Pulmonary Embolism/surgery , SARS-CoV-2 , Shock, Cardiogenic/drug therapy , Shock, Cardiogenic/etiology , Thrombectomy/instrumentation , Treatment Outcome , Vena Cava, Inferior/diagnostic imaging , Vena Cava, Inferior/surgery , Venous Thrombosis/drug therapy , Venous Thrombosis/etiology
14.
Crit Care Med ; 49(9): e870-e873, 2021 09 01.
Article in English | MEDLINE | ID: covidwho-1455369

ABSTRACT

OBJECTIVES: To describe the successful recovery from multiple and life-threatening venous thrombosis after ChAdOx1 nCoV-19 vaccination. DESIGN: Case report. SETTING: University Hospital. PATIENT: Few days after the first dose of the ChAdOx1 nCoV-19 vaccine, a 21-year-old woman experienced massive thrombosis in the deep and superficial cerebral veins together with seizures, neurologic focal deficit, and thrombocytopenia. In the neurointensive care unit, her condition worsened despite early decompressive craniectomy. She developed bilateral segmental pulmonary embolism, left hepatic, and left external iliac venous thrombosis. INTERVENTION: Argatroban (0.5-2.2 µg/kg/min) and high-dose IV immunoglobulin (1 g/kg/d for 2 consecutive days) were initiated on day 6 after admission. With these therapies, there was a gradual resolution of multiple sites of venous thrombosis, and platelet count returned to normal. The patient left the ICU with full consciousness, expressive aphasia, and right hemiparesis. CONCLUSIONS: This case of vaccine-induced immune thrombotic thrombocytopenia shows that a good outcome can be obtained even with multiple and life-threatening venous thrombotic lesions. Argatroban and high-dose IV immunoglobulin along with management of severe cerebral venous thrombosis played a major role in this epilogue.


Subject(s)
Antithrombins/therapeutic use , Arginine/analogs & derivatives , COVID-19 Vaccines/adverse effects , Pipecolic Acids/therapeutic use , Sulfonamides/therapeutic use , Thrombocytopenia/drug therapy , Venous Thrombosis/drug therapy , Arginine/therapeutic use , Cerebral Veins/diagnostic imaging , Drug Therapy, Combination , Female , Fondaparinux/therapeutic use , Humans , Immunoglobulins, Intravenous , Thrombocytopenia/etiology , Tomography, X-Ray Computed , Venous Thrombosis/etiology , Young Adult
15.
Clin Appl Thromb Hemost ; 27: 10760296211039288, 2021.
Article in English | MEDLINE | ID: covidwho-1448131

ABSTRACT

Coronavirus disease 2019 (COVID-19) is a systemic disease that can be life-threatening involving immune and inflammatory responses, and that can result in potentially lethal complications, including venous thrombo-embolism (VTE). Forming an integrative approach to thrombo-prophylaxis and coagulation treatment for COVID-19 patients ensues. We aim at reviewing the literature for anticoagulation in the setting of COVID-19 infection to provide a summary on anticoagulation for this patient population. COVID-19 infection is associated with a state of continuous inflammation, which results in macrophage activation syndrome and an increased rate of thrombosis. Risk assessment models to predict the risk of thrombosis in critically ill patients have not yet been validated. Currently published guidelines suggest the use of prophylactic intensity over intermediate intensity or therapeutic intensity anticoagulant for patients with critical illness or acute illness related to COVID-19 infection. Critically ill COVID-19 patients who are diagnosed with acute VTE are considered to have a provoking factor, and, therefore, treatment duration should be at least 3 months. Patients with proximal deep venous thrombosis or pulmonary embolism should receive parenteral over oral anticoagulants with low-molecular-weight heparin or fondaparinux preferred over unfractionated heparin. In patients with impending hemodynamic compromise due to PE, and who are not at increased risk for bleeding, reperfusion may be necessary. Internists should remain updated on new emerging evidence regarding anticoagulation for COVID-19 patients. Awaiting these findings, we invite internists to perform individualized decisions that are unique for every patient and to base them on clinical judgment for risk assessment.


Subject(s)
Anticoagulants/therapeutic use , COVID-19/complications , SARS-CoV-2 , Thrombophilia/drug therapy , Anti-Inflammatory Agents/therapeutic use , Anticoagulants/administration & dosage , Anticoagulants/adverse effects , Consensus , Critical Illness , Disease Management , Factor Xa Inhibitors/administration & dosage , Factor Xa Inhibitors/adverse effects , Factor Xa Inhibitors/therapeutic use , Female , Fibrin Fibrinogen Degradation Products/analysis , Fondaparinux/adverse effects , Fondaparinux/therapeutic use , Hemorrhage/chemically induced , Heparin/adverse effects , Heparin/therapeutic use , Heparin, Low-Molecular-Weight/administration & dosage , Heparin, Low-Molecular-Weight/adverse effects , Heparin, Low-Molecular-Weight/therapeutic use , Humans , Inpatients , Male , Practice Guidelines as Topic , Pregnancy , Pregnancy Complications, Hematologic/prevention & control , Pregnancy Complications, Infectious/blood , Pulmonary Embolism/drug therapy , Pulmonary Embolism/etiology , Pulmonary Embolism/prevention & control , Risk , Thrombophilia/etiology , Venous Thromboembolism/drug therapy , Venous Thromboembolism/etiology , Venous Thromboembolism/prevention & control , Venous Thrombosis/drug therapy , Venous Thrombosis/etiology , Venous Thrombosis/prevention & control
16.
Lancet ; 398(10306): 1147-1156, 2021 09 25.
Article in English | MEDLINE | ID: covidwho-1437625

ABSTRACT

BACKGROUND: A new syndrome of vaccine-induced immune thrombotic thrombocytopenia (VITT) has emerged as a rare side-effect of vaccination against COVID-19. Cerebral venous thrombosis is the most common manifestation of this syndrome but, to our knowledge, has not previously been described in detail. We aimed to document the features of post-vaccination cerebral venous thrombosis with and without VITT and to assess whether VITT is associated with poorer outcomes. METHODS: For this multicentre cohort study, clinicians were asked to submit all cases in which COVID-19 vaccination preceded the onset of cerebral venous thrombosis, regardless of the type of vaccine, interval between vaccine and onset of cerebral venous thrombosis symptoms, or blood test results. We collected clinical characteristics, laboratory results (including the results of tests for anti-platelet factor 4 antibodies where available), and radiological features at hospital admission of patients with cerebral venous thrombosis after vaccination against COVID-19, with no exclusion criteria. We defined cerebral venous thrombosis cases as VITT-associated if the lowest platelet count recorded during admission was below 150 × 109 per L and, if the D-dimer was measured, the highest value recorded was greater than 2000 µg/L. We compared the VITT and non-VITT groups for the proportion of patients who had died or were dependent on others to help them with their activities of daily living (modified Rankin score 3-6) at the end of hospital admission (the primary outcome of the study). The VITT group were also compared with a large cohort of patients with cerebral venous thrombosis described in the International Study on Cerebral Vein and Dural Sinus Thrombosis. FINDINGS: Between April 1 and May 20, 2021, we received data on 99 patients from collaborators in 43 hospitals across the UK. Four patients were excluded because they did not have definitive evidence of cerebral venous thrombosis on imaging. Of the remaining 95 patients, 70 had VITT and 25 did not. The median age of the VITT group (47 years, IQR 32-55) was lower than in the non-VITT group (57 years; 41-62; p=0·0045). Patients with VITT-associated cerebral venous thrombosis had more intracranial veins thrombosed (median three, IQR 2-4) than non-VITT patients (two, 2-3; p=0·041) and more frequently had extracranial thrombosis (31 [44%] of 70 patients) compared with non-VITT patients (one [4%] of 25 patients; p=0·0003). The primary outcome of death or dependency occurred more frequently in patients with VITT-associated cerebral venous thrombosis (33 [47%] of 70 patients) compared with the non-VITT control group (four [16%] of 25 patients; p=0·0061). This adverse outcome was less frequent in patients with VITT who received non-heparin anticoagulants (18 [36%] of 50 patients) compared with those who did not (15 [75%] of 20 patients; p=0·0031), and in those who received intravenous immunoglobulin (22 [40%] of 55 patients) compared with those who did not (11 [73%] of 15 patients; p=0·022). INTERPRETATION: Cerebral venous thrombosis is more severe in the context of VITT. Non-heparin anticoagulants and immunoglobulin treatment might improve outcomes of VITT-associated cerebral venous thrombosis. Since existing criteria excluded some patients with otherwise typical VITT-associated cerebral venous thrombosis, we propose new diagnostic criteria that are more appropriate. FUNDING: None.


Subject(s)
COVID-19 Vaccines/adverse effects , Intracranial Thrombosis/epidemiology , Purpura, Thrombocytopenic, Idiopathic/epidemiology , Vaccination/adverse effects , Adult , COVID-19 Vaccines/immunology , Cohort Studies , Female , Fibrin Fibrinogen Degradation Products , Humans , Intracranial Thrombosis/drug therapy , Intracranial Thrombosis/mortality , Male , Middle Aged , Platelet Count , Purpura, Thrombocytopenic, Idiopathic/drug therapy , SARS-CoV-2 , United Kingdom/epidemiology , Venous Thrombosis/drug therapy , Venous Thrombosis/epidemiology
17.
J Cardiovasc Surg (Torino) ; 62(6): 548-557, 2021 Dec.
Article in English | MEDLINE | ID: covidwho-1406908

ABSTRACT

INTRODUCTION: We aimed to review the prevalence, the risk factors and the outcomes of venous thrombosis (VT) in patients hospitalized for COronaVirus Disease 19 (COVID-19). EVIDENCE ACQUISITION: Electronic bibliographic databases were searched using the words "COVID venous thrombosis". The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement standards. EVIDENCE SYNTHESIS: The search of the literature retrieved 877 results. After assessment of full texts, 69 papers were included in the qualitative analysis and 23 of them in the quantitative evaluation. The analyzed studies included a total of 106,838 patients hospitalized for COVID-19 from January to December 2020. The pooled reported prevalence rate of VT was in median 16.7% (IQR 5.8-30%), being higher in ICU patients (60.8-85.4%). VT events were reported in about 75% of cases in the popliteal and calf veins. Signs and symptoms were present in 6.1% of cases. At quantitative evaluation, older age, D-dimer and obesity increased the odds to experience a VT (OR=3.54, 95% CI 0.65-6.43, P=0.01; OR=956.86, 95% CI 225.67-1668.05, P=0.01; OR=1.42, 95% CI 1.01-1.99, P=0.03 respectively). Female sex seemed to be protective against the odds of VT (OR=0.77, 95% CI 0.63-0.93, P=0.007). CONCLUSIONS: Among patients hospitalized for COVID-19, VT is a relatively common finding, with higher prevalence rates in ICU patients. VT occurs mostly in the distal regions of the lower limb and is asymptomatic in most cases. Older age, obesity and higher D-dimer values on admission increased the odds of VT, while female sex was protective against the odds of VT.


Subject(s)
Blood Coagulation , COVID-19/epidemiology , Venous Thrombosis/epidemiology , Age Factors , Anticoagulants/therapeutic use , Biomarkers/blood , Blood Coagulation/drug effects , COVID-19/blood , COVID-19/diagnosis , COVID-19/therapy , Fibrin Fibrinogen Degradation Products/metabolism , Hospitalization , Humans , Obesity/epidemiology , Prevalence , Prognosis , Risk Assessment , Risk Factors , Sex Factors , Venous Thrombosis/blood , Venous Thrombosis/diagnosis , Venous Thrombosis/drug therapy
18.
Radiology ; 302(2): 319-325, 2022 02.
Article in English | MEDLINE | ID: covidwho-1360579

ABSTRACT

This case series reports six patients (four men and two women; median age, 38 years; interquartile range, 26-48 years) who presented with vaccine-induced thrombocytopenia and thrombosis beginning 3-26 days after receiving the first dose of the ChAdOx1 nCoV-19 (AstraZeneca) vaccine for COVID-19. The patients were admitted to a general hospital between 9 and 31 days after the first dose. All patients had strongly detected antiplatelet factor 4 antibodies and severe thrombosis. Laboratory features included thrombocytopenia and elevated d-dimer levels. Thrombotic events were predominantly venous; two patients had arterial or mixed arterial and venous thrombosis. All patients recovered after receiving intravenous immunoglobulin and nonheparin-based anticoagulation. © RSNA, 2021 An earlier incorrect version appeared online. This article was corrected on August 18, 2021.


Subject(s)
/adverse effects , Diagnostic Imaging/methods , Thrombocytopenia/chemically induced , Thrombocytopenia/diagnostic imaging , Venous Thrombosis/chemically induced , Venous Thrombosis/diagnostic imaging , Adult , Anticoagulants/therapeutic use , COVID-19/prevention & control , Female , Fibrin Fibrinogen Degradation Products , Humans , Immunoglobulins, Intravenous/therapeutic use , Lung/diagnostic imaging , Male , Middle Aged , Retrospective Studies , SARS-CoV-2 , Thrombocytopenia/drug therapy , Venous Thrombosis/drug therapy
19.
Semin Thromb Hemost ; 48(1): 93-99, 2022 Feb.
Article in English | MEDLINE | ID: covidwho-1356595

ABSTRACT

The inflammatory process is strongly involved in the pathophysiology of venous thromboembolism (VTE) and has a significant role in disease prediction. Inflammation most probably represents a common denominator through which classical and nonclassical risk factors stimulate thrombotic process. Inflammation of the venous wall promotes the release of tissue factor, inhibits the release of anticoagulant factors, and hampers endogenous fibrinolysis. Systemic inflammatory response also inhibits restoration of blood flow in the occluded vessel. Recent studies indicate that increased inflammatory response ("cytokine storm") is related to prothrombotic state and thromboembolic events in patients with coronavirus disease 2019 (COVID-19). The growing evidence of involvement of inflammation in the pathogenesis of VTE indicates the importance of anti-inflammatory treatment and prevention of VTE. While aspirin was shown to be effective in prevention of recurrent venous thrombosis after treatment with anticoagulant drugs, some other anti-inflammatory drugs like nonsteroidal anti-inflammatory agents may have prothrombotic effect, thus potentially increasing the risk of VTE. Recently, new specific anti-inflammatory drug inhibitors of inflammatory markers that have been shown to be involved in the pathogenesis of VTE are being searched. As thrombogenesis is based on activation of coagulation provoked by inflammation, then prevention and treatment of VTE should include both anticoagulant and anti-inflammatory agents. Combined treatment is related to increased risk of bleeding complications, therefore subtherapeutic doses of both drugs should be used to improve the efficacy of management of VTE without increasing the risk of bleeding.


Subject(s)
COVID-19 , Venous Thromboembolism , Venous Thrombosis , Anticoagulants/therapeutic use , Humans , Inflammation/drug therapy , SARS-CoV-2 , Venous Thromboembolism/drug therapy , Venous Thromboembolism/etiology , Venous Thrombosis/drug therapy
20.
Ann Vasc Surg ; 77: 79-82, 2021 Nov.
Article in English | MEDLINE | ID: covidwho-1356137

ABSTRACT

A rare case of aortic thrombosis in a young COVID-19 positive patient is presented in this case report. Arterial thrombosis developed despite the administration of anticoagulants for treating DVT and PE. The patient underwent axillobifemoral bypass surgery. Limited surgical surveillance, administered steroids and critical health status resulted in wound site infection and consequent graft removal. Aortic endarterectomy and autovenous-patch plasty were performed after the patient's condition improved. Etiopathogenesis of arterial events in the setting of COVID-19 is not entirely understood. It has been suggested that SARS-CoV-2 infection strongly affects vascular endothelial glycocalyx (VEGLX), causes systemic inflammation - reactive microvascular endotheliosis (SIRME), and consequently results in arterial thrombosis.


Subject(s)
Aorta, Thoracic , Aortic Diseases/etiology , COVID-19/complications , Pulmonary Embolism/complications , Rare Diseases , Thrombosis/etiology , Venous Thrombosis/complications , Aortic Diseases/diagnosis , Aortic Diseases/surgery , Computed Tomography Angiography , Endarterectomy/methods , Endovascular Procedures/methods , Humans , Male , Middle Aged , Pulmonary Embolism/diagnosis , Pulmonary Embolism/drug therapy , SARS-CoV-2 , Thrombosis/diagnosis , Venous Thrombosis/diagnosis , Venous Thrombosis/drug therapy
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