key: cord-338896-relelmsm
authors: Naudin, Iris; Long, Anne; Michel, Christophe; Devigne, Bertrand; Millon, Antoine; Della-Schiava, Nellie
title: Acute aorto-iliac occlusion in patient with COVID-19.
date: 2020-10-17
journal: J Vasc Surg
DOI: 10.1016/j.jvs.2020.10.018
sha: 
doc_id: 338896
cord_uid: relelmsm

Coronavirus (SARS-Coronavirus-2:SARS-CoV-2) pandemic is affecting almost every country in the world. Even if the major symptoms of coronavirus disease-2019 (COVID-19) are respiratory, different symptoms at presentation are now recognized. Venous thromboembolism has been reported in infected patients and few but increasing cases of arterial thrombosis have been described. We report a case of acute aorto-iliac and lower limb artery occlusions in a patient presenting with severe COVID-19 infection. The mechanism of the occlusion seemed to be distal embolization from a floating thrombus in the aortic arch caused by a major inflammatory state and virus infection. The patient underwent aorto-iliac and lower limb artery mechanical thrombectomy but required unilateral major amputation.

calcifications of the aortic bifurcation (Fig 1) . A small thrombus was found floating in the aortic 2 arch (Fig 2) without, calcification of the arterial wall. Thoracic images were typical of COVID-3 19 pulmonary lesions (reticular interlobular septa thickening within patchy ground-glass 4 opacities (crazy paving (4)) (Fig 3) . There was no pulmonary embolism. 5

Even though at the time of admission, the PCR-test of throat-swab was negative, the patient was 6 considered COVID positive due to typical pulmonary images. Hydroxychloroquine, broad-7 spectrum antibiotics (macrolide and third-generation cephalosporin) and therapeutic 8 unfractionated heparin (UFH) treatment (20 000 international units/12h by continuous infusion, 9

with a goal of aPTT of 60-90) were initiated. Hydroxychloroquine was introduced for its 10 antiviral effect. The patient was hospitalized in a COVID-positive unit. Surgery was decided in 11 emergency without any additional imaging of the infra-inguinal arteries. Under general 12 anesthesia, via a percutaneous right common femoral and open left common femoral approach, 13 an occlusion balloon was placed in the right common iliac ostium to avoid a contralateral 14 embolization and aorto-iliac thrombectomy performed using embolectomy catheter (Fogarty, 15

Edwards, CA, USA). Voluminous, fresh-appearing thrombi were removed. (Fig 4) . No iliac 16 stenosis was found during intra operative aortography. Covered kissing stents were placed to 17 exclude residual thrombus in both common iliac arteries. Completion arteriography showed left Aorto-iliac kissing stents and right popliteal artery were observed to be patent, but a recent small 20 renal infarction with no evidence of renal thrombus was present on the right side. No other site of 21 embolization was identified. 22 1 tests and serologic testing showed lowered antithrombin value (21%), absence of anticardiolipin 2

IgG and anti-β2-glycoprotein I IgG antibodies. The last CT scan performed on May 1 st 2020 to 3 control vascular revascularization showed complete lysis of the thoracic aorta's thrombus 4 without any parietal atherosclerotic lesion as nidus. 5

At the time of manuscript submission, the patient is still in ICU after 6 weeks but is now 6 extubated and recovering. 7

He gave his consent for publication. This case also reflects the difficulties to manage therapeutic anticoagulation with UFH because 22 of such massive inflammatory reaction and because of a possible antithrombin (AT) deficit in 23 case of COVID-19 (5). AT deficit which was present in our patient on subsequent analysis, 1 might be due to liver dysfunction, consumption during clotting and heparin treatment itself (21). 2 UFH as well as low molecular weight heparin have anticoagulation effects only after binding to 3 AT. It may be useful to know the level of AT in patients with COVID-19 with acute arterial 4 occlusion in order to manage anticoagulation treatment. Heparin interruption decided because of 5 high aPTT, may have contributed to the right arterial popliteal reocclusion without lab argument 6 for disseminated intravascular coagulation or heparin induced platelet thrombopenia. During 7

phase of systemic inflammatory response (SIRS), the patient received higher doses of UFH (730 8 IU/Kg/24h). He is still treated by UFH at time of manuscript submission but at normal doses. 9

The patient presented lower back pain for three days before vascular consultation. 

Acute limb ischemia in patients with COVID-19 pneumonia

Chest CT 15 features of coronavirus disease 2019 (COVID-19) pneumonia : key points for radiologists. 16 patients with antiphospholipid antibodies?

Projection of Optimized Dosing Design of Hydroxychloroquine for the Treatment of

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2)

Hydroxychloroquine in Hospitalized Patients with Covid-19

Attributed to Chloroquine and Hydroxychloroquine: A Systematic Review of the 14

Clinical observation and management of COVID-19 patients

Abnormal coagulation parameters are associated with poor 20 prognosis in patients with novel coronavirus pneumonia