Viral Coagulopathy in Patients With COVID-19: Treatment and Care.

COVID-19 has proven to be particularly challenging given the complex pathogenesis of SARS-CoV-2. Early data have demonstrated how the host response to this novel coronavirus leads to the proliferation of pro-inflammatory cytokines, massive endothelial damage, and generalized vascular manifestations. While SARS-CoV-2 primarily targets the upper and lower respiratory tract, other organ systems are also affected. SARS-CoV-2 relies on 2 host cell receptors for successful attachment: angiotensin-converting enzyme 2 and transmembrane protease serine 2. Clinicopathologic reports have demonstrated associations between severe COVID-19 and viral coagulopathy, resulting in pulmonary embolism; venous, arterial, and microvascular thrombosis; lung endothelial injury; and associated thrombotic complications leading to acute respiratory distress syndrome. Viral coagulopathy is not novel given similar observations with SARS classic, including the consumption of platelets, generation of thrombin, and increased fibrin degradation product exhibiting overt disseminated intravascular coagulation-like syndrome. The specific mechanism(s) behind the thrombotic complications in COVID-19 patients has yet to be fully understood. Parenteral anticoagulants, such as heparin and low-molecular-weights heparins, are widely used in the management of COVID-19 patients. Beyond the primary (anticoagulant) effects of these agents, they may exhibit antiviral, anti-inflammatory, and cytoprotective effects. Direct oral anticoagulants and antiplatelet agents are also useful in the management of these patients. Tissue plasminogen activator and other fibrinolytic modalities may also be helpful in the overall management. Catheter-directed thrombolysis can be used in patients developing pulmonary embolism. Further investigations are required to understand the molecular and cellular mechanisms involved in the pathogenesis of COVID-19-associated thrombotic complications.

A Novel Endoscopic Bariatric Procedure: Results of an Experimental Study.

BACKGROUND: Surgical treatment of obesity is characterized by both early and late complications, and thus, there is a need to develop safe and non-invasive techniques. Ghrelin is an orexigenic hormone produced by the fundus of the stomach, which may represent a novel target for obesity management. Unfortunately, numerous attempts to alter ghrelin levels have failed to present significant clinical results. We describe a novel procedure that involves modifying arterial blood flow to the gastric fundus for limiting plasma ghrelin levels. METHODS: A gastroscope was advanced into the gastric fundus of 13 healthy Yorkshire swine, and the fundus was clipped under direct visualization to restrict left gastric artery blood flow. Body weights and ghrelin levels were recorded before and once a week for 4 weeks after the procedure. RESULTS: Compared to controls, gastroscopic clipping of the fundus decreased plasma ghrelin levels and prevented further weight gain in the 4 weeks of follow-up. Immunohistochemistry and histomorphometry revealed reduced numbers of ghrelin-positive cells in the fundus of experimental animals. We also observed thrombosis in submucosal arteries and submucosal fibrosis. Histological studies demonstrated minimal gastric mucosal injury. CONCLUSION: Gastroscopic clipping of the fundus in an experimental porcine model resulted in sustained weight loss and a reduction in plasma ghrelin levels at 1 month post-procedure, with no adverse events. Further experimental studies in human patients are needed to examine the clinical utility of this procedure and to optimize a technique, which can facilitate adequate weight loss while minimizing the risk of mucosal injury.

Phase 1 Trial of Autologous Bone Marrow Stem Cell Transplantation in Patients with Spinal Cord Injury.

Introduction. A total of 18 patients, with complete motor deficits and paraplegia caused by thoracic and lumbar spine trauma without muscle atrophy or psychiatric problems, were included into this study. Materials and Methods. The bone marrow was aspirated from the anterior iliac crest under local anesthesia and the mononuclear fraction was isolated by density gradient method. At least 750 million mononuclear-enriched cells, suspended in 2 mL of saline, were infused intrathecally. Results and Discussion. The study reports demonstrated improvement of motor and sensory functions of various degrees observed in 9 of the 18 (50%) cases after bone marrow stem cell transplantation. Measured by the American Spinal Injury Association (ASIA) scale, 7 (78%) out of the 9 patients observed an improvement by one grade, while two cases (22%) saw an improvement by two grades. However, there were no cases in which the condition was improved by three grades. Conclusions. Analysis of subsequent treatment results indicated that the transplantation of mononuclear-enriched autologous BMSCs is a feasible and safe technique. However, successful application of the BMSCs in the clinical practice is associated with the necessity of executing more detailed examinations to evaluate the effect of BMSCs on the patients with spinal cord injury.

A novel 14F endograft for abdominal aortic aneurysm: first in man.

OBJECTIVE: This study evaluated the feasibility of percutaneous endovascular treatment of infra-renal abdominal aortic aneurysm (AAA) using the novel low profile modular Tripelay system (Tripelay, France). BACKGROUND: Endovascular aortic aneurysm treatment (EVAR) has become more widely used as early mortality has been significantly reduced. Also, percutaneous access has become possible with the introduction of vascular closure devices and with the initial reduction in size of delivery catheters. However, percutaneous access is not commonly used and anatomical considerations, such as access vessel size and tortuousities, preclude a number of patients from being efficiently treated with EVAR. METHODS: The novel Tripelay system enables two semicircular preshaped self-expandable stentgrafts to be positioned side by side on the aneurysm neck extending into the iliac arteries. Each stentgraft being smaller than the target vessel diameter, the delivery catheter is reduced in size (14F) and accommodates with smaller and more tortuous access vessels than conventional devices. This device was used to treat a 57-year-old male patient with significant comorbidities (previous coronary artery bypass grafting (CABG) and abdominal surgeries, smoking, hypertension, obesity, hyperlipidemia). Percutaneous access was made on both femoral arteries. The device was inserted, positioned, and deployed as planned. Iliac extensions were used bilaterally. RESULTS: The EVAR procedure was performed successfully, and the patient was discharged on day 6. Follow-up computed tomography scans at 1, 6, and 12 months revealed perfect exclusion of the aneurysm sac, patent stentgraft, and vessels, and no prosthesis migration, endoleaks or stent fracture were observed. The patient remained asymptomatic and reported no adverse events during that period. CONCLUSION: The Tripelay system seemed as an effective and user friendly tool for treatment of AAAs. Of course, this procedure still needs further clinical evaluation with more cases and longer follow-up to confirm long-term efficacy and safety of this device.