Pulmonary embolism or thrombosis in ARDS COVID-19 patients: A French monocenter retrospective study

Abstract

Hypercoagulability and endotheliopathy reported in patients with coronavirus disease 2019 (COVID-19) combined with strict and prolonged immobilization inherent to deep sedation and administration of neuromuscular blockers for Acute Respiratory Distress Syndrome (ARDS) may expose critically ill COVID-19 patients to an increased risk of venous thrombosis and pulmonary embolism (PE). We aimed to assess the rate and to describe the clinical features and the outcomes of ARDS COVID-19 patients diagnosed with PE during ICU stay. From March 13 th to April 24 th 2020, a total of 92 patients (median age: 61 years, 1st-3rd quartiles [55-70]; males: n = 73/92, 79%; baseline SOFA: 4 [3-7] and SAPS II: 31 [21-40]; invasive mechanical ventilation: n = 83/92, 90%; ICU mortality: n = 45/92, 49%) were admitted to our 41-bed COVID-19 ICU for ARDS due to COVID-19. Among them, 26 patients (n = 26/92, 28%) underwent a Computed Tomography Pulmonary Angiography which revealed PE in 16 (n = 16/26, 62%) of them, accounting for 17% (n = 16/92) of the whole cohort. PE was bilateral in 3 (19%) patients and unilateral in 13 (81%) patients. The most proximal thrombus was localized in main (n = 4, 25%), lobar (n = 2, 12%) or segmental (n = 10, 63%) pulmonary artery. Most of the thrombi (n = 13/16, 81%) were located in a parenchymatous condensation. Only three of the 16 patients (19%) had lower limb venous thrombosis on Doppler ultrasound. Three patients were treated with alteplase and anticoagulation (n = 3/ 16, 19%) while the 13 others (n = 13/16, 81%) were treated with anticoagulation alone. ICU mortality was higher in patients with PE compared to that of patients without PE (n = 11/16, 69% vs. n = 2/10, 20%; p = 0.04). The low rate of lower limb venous thrombosis together with the high rate of distal pulmonary thrombus argue for a local immuno-thrombotic process associated with the classic embolic process. Further larger studies are needed to assess the real prevalence and the risk factors of pulmonary embolism/thrombosis together with its prognostic impact on critically ill patients with COVID-19.

Pathophysiological Processes Underlying the High Prevalence of Deep Vein Thrombosis in Critically Ill COVID-19 Patients

“…One major consequence is the high prevalence of deep vein thrombosis (DVT) demonstrated by studies performing duplex ultrasound examination of the lower limbs in patients hospitalized with severe pneumonia ( Zhang et al, 2020 ; Fraissé et al, 2020 ; Llitjos et al, 2020 ; Nahum et al, 2020 ; Ren et al, 2020 ; Voicu et al, 2020a ). The high prevalence of DVT exposes patients to a high risk of pulmonary embolism (PE) ( Contou et al, 2020 ; Poissy et al, 2020 ), especially when DVT is proximal, at the popliteal level, or above ( Konstantinides et al, 2020 ). DVT in COVID-19 patients may be responsible for approximately 10% of deaths in COVID-19 patients as shown by systematic autopsy findings ( Edler et al, 2020 ).…”

COVID-19 as cause of viral sepsis: A Systematic Review and Meta-Analysis

“…Of the 104 included studies, mainly observational retrospective, 42 were reporting results from China (19-60), 19 from the U.S.A (61-79), 5 from the U.K (80-84), 24 across Europe, mainly Italy, Spain, France and the Netherlands (85-109), 10 from other countries (110-119) and 3 were international (120-122). All studies reported data on hospitalized patients due to COVID-19 and 35 of them included data for ICU nnnnnn(20, 25, 33, 36, 37, 41, 44, 45, 48, 52, 53, 56, 58, 66, 72, 73, 81-84, 86-89, 95, 96, 98, 101, 103, 106, 107, 109, 111, 119). Eight studies were pediatric (59, 60, 78, 79, 83, 84, 118, 119).…”

Clinical Outcomes of Pulmonary Embolism in Mexican Patients With COVID-19

“…Severe Acute Respiratory Syndrome Coronavirus 2 (SARS CoV-2) infection is characterized by fever and respiratory symptoms, 1 however, patients infected with SARS CoV-2 may present with a broad clinical spectrum, ranging from an asymptomatic disease to acute respiratory distress syndrome and multi-organ failure. Patients with COVID-19 infection have been reported to suffer from coagulation abnormalities consistent with infection-induced inflammatory changes, 2 – 4 in addition, Ackermann and colleagues 5 reported the presence of endothelial lesions, such as intercellular union disruption, disrupted cell membranes and cellular edema in the pulmonary endothelium during their post mortem study of 7 lungs obtained from patients who died from COVID-19. Not only do these patients often go through a hypercoagulability state but are also prone to suffer from prolonged immobilization; this leads critically ill patients to an increased risk of Venous Thromboembolism (VTE) and Pulmonary Embolism (PE).…”

“… 14 VTE has been associated with a poor prognosis and PE may be a turning point in these patients due to the increased hypoxemia and cardiac collapse. 2 , 3 , 10 We aimed to describe the clinical characteristics and outcomes of 26 COVID-19 patients diagnosed with PE during their hospital stay in a tertiary referral center for COVID-19 in Mexico City.…”