key: cord-290065-ouua7wnq
authors: Kashi, Mahine; Jacquin, Aurélien; Dakhil, Bassel; Zaimi, Rym; Mahé, Emmanuel; Tella, Emilie; Bagan, Patrick
title: Severe arterial thrombosis associated with Covid-19 infection
date: 2020-05-16
journal: Thromb Res
DOI: 10.1016/j.thromres.2020.05.025
sha: 
doc_id: 290065
cord_uid: ouua7wnq

• Increased incidence of venous thrombosis has been demonstrated in SARS-CoV2 infected patients but no data are available for arterial thrombosis. • We observed very severe arterial thrombotic complications in COVID-19 patients with cardiovascular history despite the use of antiplatelet or anticoagulant therapy, including five irreversible lower limb ischemia and two thoracic aortic free floating thrombi. • Three patients were in intensive care unit (ICU) and two of them also presented VTE, one deep vein thrombosis and one segmental PE. • Further studies are needed to evaluate the necessity of therapeutic anticoagulation in COVID-19 patients with peripheral arterial occlusive disease or thrombophilia.

J o u r n a l P r e -p r o o f 2 Dear Editor, we were very interested to read the article published by Klok et al. reporting the incidence of thrombotic complications in critically ill ICU patients diagnosed with Covid-19 1 . The article highlighted the high rate of venous thromboembolism (VTE) and arterial thrombotic events within this population. Many publications have reported cardiovascular complications associated to SARS-CoV2 infection [1] [2] [3] [4] . However, few are focused on systemic arterial embolism 1 .

We report seven cases of severe arterial thrombotic events in patients infected with Covid-19. These patients developed rapidly progressive lower limb ischemia or formation of mobile aortic thrombi (Table 1) .

Covid-19 diagnosis was made by PCR assay and/or chest computed tomography (CT) associated to respiratory symptoms in all cases. In case of respiratory deterioration, CT pulmonary angiography was performed to look for an acute pulmonary embolism (PE). Symptomatic arterial thrombosis was diagnosed clinically and confirmed by a color doppler duplex ultrasonography (CDDUS) and/or CT angiography (CTA).

All patients had a history of cardiovascular disease (Table 1) . Five patients were diagnosed with irreversible lower limb ischemia. Three patients were hospitalized in the intensive care unit (ICU) under therapeutic anticoagulation for acute or chronic arrhythmia or thrombophilia. In two cases, therapeutic anticoagulation had to be switched to a prophylactic dose 72 hours before the arterial event because of melena. A conservative treatment was decided by a multidisciplinary team considering the severity of respiratory distress and multiple organ dysfunction. In two cases, asymptomatic floating thoracic aortic thrombi were detected on a pulmonary angiography that had been performed after respiratory deterioration. No previous images were available for comparison.

Two patients had history of lower limb vascular surgery. One of them underwent surgery after lower limb CDDUS confirmed long segment occlusion from the right common iliac artery to the femoral tripod. On We describe very severe arterial thrombotic complications occurring in COVID-19 patients despite the use of antiplatelet or anticoagulant therapy, including irreversible lower limb ischemia and free floating thrombi in the thoracic aorta. Since the beginning of the pandemic we have noticed an unusual severity of lower limb ischemia, partly explained by the healthcare system saturation resulting in delayed patient presentation. We were also confronted with unusual extension or localization of arterial thrombosis diagnosed in a short period of time.

Other studies have shown cardiovascular disease to be an independent risk factor of pejorative outcome, and myocardial injury to be associated to a heavy mortality rate in COVID-19 2,3,4 . Recent publications have highlighted a coagulation disorder in severely diseased patients 3,5 , responsible for a hypercoagulable state which might explain disseminated intravascular coagulation and organ failure. Some hypothesize a direct effect of coronavirus on vascular endothelial cells to justify acute arterial thrombosis 4,6 .

As a result, systematic thrombosis prophylaxis in patients presenting sepsis induced coagulopathy score ≥4 or D-dimer > 3.0 ug/mL is recommended 6 

Incidence of thrombotic complications in critically ill ICU patients with COVID-19

Potential Effects of Coronaviruses on the Cardiovascular System: A Review

Cardiovascular Considerations for Patients, Health Care Workers, and Health Systems During the Coronavirus Disease

Will Complement Inhibition be the New Target in Treating COVID-19 Related Systemic Thrombosis? Circulation. 2020

Prominent changes in blood coagulation of patients with SARS-CoV-2 infection

Anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy

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