key: cord-258758-sz8chn5e
authors: Resch, Tim; Vogt, Katja; Md, Nikolaj Eldrup.
title: Atypical COVID -19 presentation in patient undergoing staged TAAA repair
date: 2020-05-16
journal: J Vasc Surg Cases Innov Tech
DOI: 10.1016/j.jvscit.2020.05.001
sha: 
doc_id: 258758
cord_uid: sz8chn5e

This report outlines a case of atypical presentation of Covid 19 viral infection. A 65-year old male was planned for a two staged repair of a Crawford type 3 thoracoabdominal aortic aneurysm. The first stage, TEVAR in descending aorta, was uneventful and patient was discharged on postoperative day 2. He was readmitted 10 days later, presenting with diarrhea, lower limb pain and weakness after 25 meters walking. The patient displayed no fever or upper respiratory tract signs or symptoms. Computer tomography and MR of the spinal cord were normal. Patient was tested positive for Covid 19 virus and later during hospitalization developed more typical fever and respiratory symptoms that were managed medically.

The COVID 19 pandemic is causing a major strain on hospital resources around the globe. The 2 typical presenting symptoms in the majority of patients range from common upper respiratory 3 tract signs such as cough, sore throat and fever to more severe shortness of breath and severe 4 respiratory dysfunction. In some patients this might lead to pneumonia, ARDS and ventilator 5 dependency. 6 In addition, milder symptoms, not commonly associated with upper respiratory tract infection 7 (URTI) can be the only presenting symptoms. These symptoms include loss of smell and taste, 8 stomach aches, body aches and nausea. 9 We present a case of COVID 19 infection with atypical debut in a patient having undergone 10 staged, endovascular thoraco-abdominal repair 2 weeks previously. The patient allowed 11 publication of this case and images. hypertension and left renal artery stenosis, which then was treated with a renal stent, creatinine at 1 admission was normal. 2 At initial referral, a computer tomography angiography (CTA) confirmed a 6,3 x 7,3 cm type III 3 Crawford thoraco-abdominal aneurysm (TAAA), extending from the mid descending thoracic 4 aorta to the aortic-iliac bifurcation (fig 1a +b) . The descending aorta was ectatic and "shaggy" 5 with large amounts of irregular intraluminal thrombus (Fig. 2) . The left kidney was anthropic and 6 renal scintigraphy confirmed that the left kidney only contributed 22% of overall renal function.

Due to the patient's multiple comorbidities he was considered unsuitable for open TAAA repair.

He was found anatomically suitable for an endovascular repair with a 4 fenestrated endovascular 9 graft. There was some question as to the caliber and suitability of the iliac access vessels and 10 there was also a high risk for distal thrombus embolization from the shaggy descending thoracic 11 aorta. To minimize the risk of spinal cord ischemia (SCI) and to evaluate and optimize the iliac 12 access, the procedure was planned for 2 stages with a 4-6-week interval for recovery and 13 development of collateral pathways to the spinal cord. 14 The patient underwent stage 1, percutaneous thoracic endovascular repair (TEVAR) with 15 placement of a thoracic stent-graft from the left subclavian artery to 4 cm proximal to the celiac 16 artery origin (Fig 3) . The patient was observed in the intensive care unit (ICU) with a SCI 17 protocol for 36 hours postoperatively and was then observed an additional24 hours in the 18 vascular department before discharge to home. At discharge, ABI was unchanged and Creatinine 19 normal. The patient was scheduled for the second stage procedure after 4-6 weeks with final 20 exclusion of the aneurysm with a fenestrated stent-graft.

Ten days after discharge the patient returned emergently to the outpatient clinic with complaints 1 of leg pain on exertion bilaterally. No pain at rest. He also describes vertigo on postural changes 2 and that his legs feel weak and "give way" after 25meters of walking. The symptoms had started 3 2-3 days after discharge and for the last two days he also described diarrhea twice daily. No 4 fevers, chills or nausea. On physical exam the patient was somewhat ashy in appearance.

Abdomen was soft and non-tender. Foot pulses and ABI's were unchanged and there were no 6 signs of lower limb weakness or sensory loss. Patients contacts were traced and questioned for symptoms. However, testing was not performed 1 on asymptomatic individuals at that time. As the patient was isolated on submission due to GI 2 disease, the patient was isolated before he was tested for Covid and staff used gown, gloves and 3 mask when in contact with him. The typical and most common presentation of COVID 19 is that of upper respiratory tract 7 infection with fever, cough and respiratory distress (7). Symptoms vary from very mild to very 8 severe and the incubation period is 2-14 days, with increasing symptoms over time. However, as 9 in the current case, Covid 19 can also present in an atypical fashion clouding diagnosis 10 particularly in the setting of concurrent diseases or treatments.

Endovascular thoraco-abdominal aortic aneurysm repair is a procedure that carries a significant 12 risk of spinal cord ischemia due to blockage of critical collateral supply to the spinal cord during 13 the procedure (1). The more anatomically extensive the repair is, the higher the risk. Patients that 14 have shaggy aorta (aortic intra luminal wall thrombus) seem to be at even higher risk due to 15 athero-embolic embolization peri-procedurally (2). In addition, complications leading to drop in 16 blood pressure in the perioperative period are also considered aggravating factors. These can 17 consist of perioperative bleeding complications often connected to poor iliac access (narrow iliac 18 diameter preventing stent graft delivery). Due to these risks, if possible, a staged approach is 19 recommended for elective TAAA repair (3-4). This allows both for collateral network 20 mobilization to the SC and avoids some risks of perioperative bleeding complications occurring 21 in the same setting as a complete elective TAAA repair (5-6).

In the current case, the patient presented with symptoms of buttock claudication and leg 1 weakness, as in a Leriche syndrome (pain, fatigue, or cramping in the legs and buttocks, pale and 2 cold legs, and erectile dysfunction due to aorto-iliac occlusion), or of delayed onset SCI with 3 lower extremity weakness which has been described after endovascular TAAA repair. His hospitalization. At that stage of the pandemic, no routine testing of asymptomatic patients was 10 performed. However, the incidence of Covid-19 was low in Denmark at the time and the 11 prevalcence in the hospital was equally low. Staff were required to stay home if they displayed 12 minimal signs of URTI.

The present case has not changed the staging policy or staging duration at the department. This is 14 due to the fact that overall, the threshold for aneurysm repair at this time has been raised to 7cm.

In addition, at the present time, all patients admitted to the hospital for overnight stay are tested 16 for corona virus. Given the coagulopathy associated with Covid 19, inflammatory markers 17 including CRP will be re-checked before proceeding with stage two of the repair. 

Short-term outcome of spinal cord ischemia after endovascular repair of thoracoabdominal aortic 3 aneurysms

A shaggy aortya is associated 6 with mesenteric embolization in patients undergoing fenestrated endografts to treat paravisceral 7 aortic aneurysms

Staged endovascular repair of thoracoabdominal 9 aortic aneurysms limits incidence and severity of spinal cord ischemia

Staged repair significantly reduces paraplegia rate after extensive thoracoabdominal 12 aortic aneurysm repair

Measuring the collateral 15 network pressure to minimize paraplegia risk in thoracoabdominal aneurysm resection

The collateral network 19 concept: remodeling of the arterial collateral network after experimental segmental artery 20 sacrifice