Bilateral Acute Lower Limb Ischemia Secondary to COVID-19.

COVID-19 has to date affected over 5 million people worldwide and caused in excess of 300000 deaths. One of the principal finding is that of a thrombotic tendency within the lungs leading to high mortality. There have been increasing number of reports of peripheral arterial thrombosis as well. Most cases of arterial thrombosis is noted in patient in intensive care setting. Here-in we report a case of acute bilateral lower limb arterial thrombosis in a patient recovering at home with mild COVID-19 symptoms, highlighting that patients with milder symptoms may also suffer from prothrombotic state resulting in acute arterial occlusions. Arterial thrombosis should be suspected in these patients despite the absence of predisposing factors.

Arterial Thrombosis in Coronavirus Disease 2019 Patients: A Rapid Systematic Review.

BACKGROUND: Emerging evidence suggests that severe form of coronavirus disease 2019 (COVID-19) is mediated, in part, by a hypercoagulable state characterized by micro- and macro-vascular thrombotic angiopathy. Although venous thrombotic events in COVID-19 patients have been well described, data on arterial thrombosis (AT) in these patients is still limited. We, therefore, conducted a rapid systematic review of current scientific literature to identify and consolidate evidence of AT in COVID-19 patients. METHODS: A systematic search of literature was conducted between November 1, 2019, and June 9, 2020, on PubMed and China National Knowledge Infrastructure to identify potentially eligible studies. RESULTS: A total of 27 studies (5 cohort, 5 case series, and 17 case reports) describing arterial thrombotic events in 90 COVID-19 patients were included. The pooled incidence of AT in severe/critically ill intensive care unit-admitted COVID-19 patients across the 5 cohort studies was 4.4% (95% confidence interval 2.8-6.4). Most of the patients were male, elderly, and had comorbidities. AT was symptomatic in >95% of these patients and involved multiple arteries in approximately 18% of patients. The anatomical distribution of arterial thrombotic events was wide, occurring in limb arteries (39%), cerebral arteries (24%), great vessels (aorta, common iliac, common carotid, and brachiocephalic trunk; 19%), coronary arteries (9%), and superior mesenteric artery (8%). The mortality rate in these patients is approximately 20%. CONCLUSIONS: AT occurs in approximately 4% of critically ill COVID-19 patients. It often presents symptomatically and can affect multiple arteries. Further investigation of the underlying mechanism of AT in COVID-19 would be needed to clarify possible therapeutic targets.

Femoral Arterial Thrombosis in a Young Adult after Nonsevere COVID-19.

INTRODUCTION: Few cases of arterial thromboembolisms have been reported after novel coronavirus disease 2019 (COVID-19) in case of severe infection or in elderly patients. We report a case of femoral arterial thrombosis in a young patient after nonsevere infection. CASE DESCRIPTION: A common femoral artery thrombosis extended in the first third of superficial and profunda femoral arteries associated with tibial posterior and popliteal artery thrombosis was diagnosed in a 24-year-old man complaining of right lower limb pain for one month. The evolution was good after anticoagulation and antiaggregant treatments and thrombectomy. Etiologic assessment was negative except for nonsevere COVID-19. DISCUSSION: COVID-19 accesses host cells via angiotensin-converting enzyme 2 protein, abundant in the lungs, which is also expressed by endothelial cells and is associated with important inflammatory syndrome and coagulopathy, leading to vascular lesions. Thrombosis prevalence is not fully established and seems to be higher in case of major inflammation and in the intensive care unit (ICU). Arterial thromboembolisms are described in many vascular territories, each time in elderly patients, or in case of severe infection. We described a femoral arterial thrombosis in a young patient with negative etiological assessment except nonsevere COVID-19. Treatment consists in anticoagulation and antiaggregant drugs and thrombectomy. Preventing venous thromboembolism treatment is recommended in case of severe infection or in the ICU, but there is no clear recommendation for arterial thromboembolism prevention. This case should lead us to be very careful of the arterial event risk even if the infection is nonsevere and the patient is young.

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.

Management of HIV vasculopathy - a South African experience.

UNLABELLED: The aim of the study was to describe the presentation management and short term results of therapy (< 1 month) in patients admitted with HIV vasculopathy. Records were culled from a prospectively maintained data base on the Vascular Unit at Inkosi Albert Luthuli Hospital, Durban, South Africa between January 2005 and June 2009. 226 patients were studied; 111 had aneurysms and 115 occlusive disease. 98% were African and ages ranged from 4-53 years (average 36); 90% were male. The CD4 count ranged from 1-930 cells/mm(3) while serum albumin averaged 30 mMol/L. 202 aneurysm presented in 111 participants; commonest sites were superficial femoral artery (40%) and carotid (25%). 82 patients had standard operative repair and 8 had stent grafts; 29 were not treated due to advanced disease. Within 30 days of operation the mortality was 9% with 5% developing graft sepsis and 11% pulmonary complications. Of 115 with occlusive disease, there were 2 distinct groups. 51 had no previous claudication and had acute thrombosis; no thrombophilia could be demonstrated. 64 had premature atherosclerotic disease. The majority presented with critical ischaemia. In the acute thrombosis group 15 (29%) had primary amputation, limb salvage was achieved in 13 (36%) and 4 died (11%). In the chronic occlusive group 30 (47%) had primary amputation, of 25 submitted to surgery limb salvage was achieved in 17 (68%). Low CD4 count and albumin levels did not correlate with mortality or complications. CONCLUSION: Surgical therapy for aneurysm is worthwhile in the short term. Following occlusive disease there is a 25% overall salvage rate in the short term (< 1/12) but the long term outlook is uncertain.

Periodontitis may increase the risk of peripheral arterial disease.

OBJECTIVES: The aim of this case control study was to evaluate whether periodontitis was associated with peripheral arterial disease (PAD). SUBJECTS AND METHODS: Twenty-five patients diagnosed with aorto-iliac and/or femoro-popliteal occlusive disease and thirty-two generally healthy control subjects were enrolled in this study. Polymerase chain reaction (PCR) was used to identify Porphyromonas gingivalis, Treponema denticola, Actinobacillus actinomycetemcomitans, Prevotella intermedia, Cytomegalovirus (CMV), Chlamydia pneumoniae, and Helicobacter pylori in tissue specimens taken from the anastomotic site of distal bypasses. Periodontal status was evaluated; serum IgG titres against the four listed bacteria were measured. RESULTS: Periodontopathic bacteria were detected in 13/25 (52%) atherosclerotic specimens. CMV or C. pneumoniae was detected in 1/25 (4%) specimens; H. pylori was not detected from any of these specimens. Fontaine grade III or IV patients showed higher detection frequency of P. gingivalis than Fontaine grade II patients (57.1% vs 22.2%, P=0.09). After adjusting for age, gender, diabetes and smoking, periodontitis increased 5-fold the risk of having PAD (OR 5.45). There were preliminary indications that periodontitis was associated with increased serum IL-6 and TNF-alpha concentrations. CONCLUSIONS: This study suggests that periodontitis may be associated with an increased risk of PAD. This association could result from the increased concentration of serum inflammatory cytokines in those with periodontitis.

Aorto-femoral bypass in the HIV infected patient.

We describe a 49-year old male Nigerian with HIV infection who presented in our institution with aorto-iliac arterial occlusive disease and progressive severe ischaemic changes of the lower extremity. His preoperative CD4 count was 43 cells / microlitre. He underwent a successful intra-peritoneal aorto-femoral bypass. This report illustrates that vascular reconstruction in an HIV infected patient can be successfully performed with minimal morbidity despite a high risk factor for major infection. The histological finding was in keeping with an accelerated atherosclerosis resulting from HIV infection.

Vascular disease in HIV/AIDS patients.

OBJECTIVES: An ongoing prospective clinical survey to determine the spectrum of vascular disease in HIV/AIDS patients and the risk factors affecting clinical outcome in order to formulate a management protocol for future use. METHODS: Comprehensive screening for risk factors for vascular disease as well as HIV/AIDS-related conditions. Disease pattern and presentation are noted and patients treated accordingly. Vascular emergencies are managed regardless of HIV status because this information is usually not available at the time of presentation. Elective management is based on immune status and risk stratification. RESULTS: 42 patients tested positive for HIV. The majority of patients presented with occlusive disease (57%), followed by aneurysms (21%) and vascular trauma (19%). A variety of vascular surgical procedures were performed on 36 patients. There was no surgical mortality and 10 patients developed complications, including 2 amputations and 7 cases of minor wound sepsis. The 3 patients who received preoperative antiretroviral therapy showed a marked reduction in viral count and a significant improvement in CD4 T-cell count. CONCLUSION: Surgery can be safe and effective in HIV-positive patients provided the necessary precautions are taken to reduce surgical morbidity.

Severe digital arterial occlusive disease and acute parvovirus B19 infection.

We report a case of arterial occlusive disease and digital ischaemia associated with acute parvovirus B19 infection. Treatment with intravenous epoprostanol improved her symptoms.

New imaging findings in a patient with central nervous system dysfunction after bone marrow transplantation.

Central nervous system disorders are an important complication of bone marrow transplantation (BMT). We have recently performed cerebral angiography to examine central nervous system dysfunction in a 22-year-old woman with acute lymphoblastic leukaemia who had undergone BMT. Angiography demonstrated multiple stenoses and occlusions in the peripheral branches of the anterior and middle cerebral arteries, a pattern similar to that seen in vasculitis. She was thought to most likely have cytomegalovirus (CMV) vasculitis, but other forms of vasculitis, such as angiitis-like-syndrome-associated graft-versus-host disease could not be excluded. This case suggests that CMV vasculitis may cause central nervous system dysfunction after BMT and that imaging studies may provide useful information about central nervous system disorders in these patients.

Increased incidence of cardiac complications in kidney transplant recipients with cytomegalovirus disease.

BACKGROUND: The transplant literature has not shown cytomegalovirus (CMV) disease to be a significant risk factor for posttransplant cardiac complications. A large number of nontransplant studies have, however, reported an association between coronary heart disease (CHD) and CMV disease. Pathology studies have demonstrated a high incidence of CMV in atheromatous plaques from the coronary circulation. METHODS: We performed multivariate analysis to determine if posttransplant CMV disease was a significant risk factor for cardiac complications in kidney transplant recipients. We also performed univariate analysis to determine which cardiac complications were more common in the recipients with CMV disease. RESULTS: Between January 1, 1984 and June 30, 1997, 1859 adults underwent kidney transplants at our institution. Of these, 377 developed one of the following cardiac complications posttransplant: myocardial infarction, angina, arrhythmia, congestive heart failure, and angiographic vessel occlusion. By multivariate analysis, significant risk factors for one of the above cardiac complications were recipient age >50 years [odds ratio (OR)=2.5, P=0.0001], diabetes (OR=1.99, P=0.0001), a history of cardiac disease pretransplant (OR= 1.34, P=0.04), and CMV disease (OR=1.5, P=0.01). Univariate analysis demonstrated that recipients with CMV disease had a higher overall incidence of cardiac complications. Arrhythmias, congestive heart failure, and vessel occlusion were more common in those with CMV disease. The incidence of myocardial infarction, angina, and cardiac arrest did not differ between the two groups (recipients with versus without CMV disease). CONCLUSIONS: CMV disease is associated with an increased risk of cardiac complications in kidney transplant recipients. In our series, angiographic vessel occlusion was more common in recipients with CMV disease. This interesting finding may support the theory that CMV plays some role in the pathogenesis of CHD.