Acute thrombotic manifestations of coronavirus disease 2019 infection: Experience at a large New York City health care system

Abstract

Introduction COVID-19 is a novel coronavirus which typically results in upper respiratory symptoms. However, we describe the acute arterial and venous thrombotic events following COVID-19 infection. Managing acute thrombotic events from the novel virus presents unprecedented challenges during the COVID-19 pandemic. Our study highlights the unique management of these patients and discusses the role of anticoagulation in patients diagnosed with COVID-19. Methods Data for 21 patients with laboratory confirmed COVID-19 disease and acute venous or arterial thrombosis were collected. Patients were analyzed on the basis of demographics, comorbidities, home medications, laboratory markers, and outcomes. The primary postoperative outcome of interest was mortality and secondary outcomes were primary patency and morbidity. To assess for significance, univariate analysis was performed using Pearson χ2 and Fisher exact tests for categorical variables and Student t-test for continuous variables. Results 21 patients with acute thrombotic events met our inclusion and exclusion criteria. The majority of cases were acute arterial events (76.2%) while the remainder were venous cases (23.8%). The average age of all patients was 64.6 years-old and 52.4% were male. The most prevalent comorbidity in the group was hypertension (81.0%). Several markers were markedly abnormal in both arterial and venous cases, including an elevated neutrophil: lymphocyte ratio (8.8) and d-dimer (4.9 mcg/mL). Operative intervention included percutaneous angiogram in 25.00% of patients and open surgical embolectomy in 23.8%. The majority of arterial interventions had a postoperative complication (53.9%) versus a 0% complication in the venous interventions. AKI on admission was a factor in 75.0% of mortalities versus 18.2% in survivors (p=0.04). Conclusion We describe our experience in the epicenter of the pandemic of 21 patients who experienced major thrombotic events from COVID-19. Our cohort highlights the need for increased awareness of vascular manifestations of COVID-19 and the important role of anticoagulation in these patients. More data is urgently needed to optimize treatments and prevent further vascular complications of COVID-19 infections.

Thrombotic complications of COVID-19

“…Acute limb ischemia (ALI) is an important consideration in patients with COVID-19 [26]. There have been over a dozen case reports and case series of ALI described in the literature [27][28][29][30][31][32][33][34][35][36][37][38][39][40][41]. These patients often have multiple thromboses involving different vessels throughout their bodies [27,31,[33][34][35][36][37][38]40].…”

“…These patients often have multiple thromboses involving different vessels throughout their bodies [27,31,[33][34][35][36][37][38]40]. Many of these patients do not have existing peripheral arterial disease [27][28][29][30][31]34,36,37,40,41]. Acute limb ischemia can even occur among patients already receiving thromboprophylaxis [34,37,39,41].…”

“…Many of these patients do not have existing peripheral arterial disease [27][28][29][30][31]34,36,37,40,41]. Acute limb ischemia can even occur among patients already receiving thromboprophylaxis [34,37,39,41].…”

“…While a computed tomographic angiogram (CTA) of the extremity is often performed, clinicians should consider adding a CTA of the aorta to evaluate for a concomitant aortic thrombosis [27,37,40]. Treatment involves vascular surgery and interventional radiology consultation, as well as empiric systemic anticoagulation [41,42]. One study of 20 patients found that operative treatment was performed in 17 patients and was able to successfully salvage the limb in 12 (70.6%) [33].…”

A review of acute limb ischemia in COVID-positive patients

“…One of the interesting findings regarding the clinical presentation of ALI among patients with COVID-19 infection is that it is rather unpredictable and not necessarily associated with severity of the disease and viral load [25 , 26] . A significant number will present in the setting of critical illness.…”