key: cord-0817629-qa318whe authors: Wu, Maddalena Alessandra; Colombo, Riccardo; Arquati, Massimo; Ippolito, Sonia; Taino, Alba; Ruggiero, Diego; Tonelli, Francesca; Trombetta, Lucia; Facchinetti, Pietro; Glielmo, Pierluigi; Cogliati, Chiara; Flor, Nicola title: Clinical–radiological correlations in COVID‐19‐related venous thromboembolism: Preliminary results from a multidisciplinary study date: 2021-05-29 journal: Int J Clin Pract DOI: 10.1111/ijcp.14370 sha: 818665503bc0a54994e2771a26448e1c378adfca doc_id: 817629 cord_uid: qa318whe INTRODUCTION: Among the multiple complex pathophysiological mechanisms underlying COVID‐19 pneumonia, immunothrombosis has been shown to play a key role. One of the most dangerous consequences of the prothrombotic imbalance is the increased incidence of micro‐ and macrothrombotic phenomena, especially deep vein thrombosis (DVT) and pulmonary embolism (PE). METHODS: We investigated the correlation between radiological and clinical–biochemical characteristics in a cohort of hospitalised COVID‐19 patients. RESULTS: PE was confirmed in 14/61 (23%) patients, five (35.7%) had DVT. The radiographic findings, quantified by Qanadli score calculated on CT angiography, correlated with the clinical score and biochemical markers. The ratio between the right and left ventricle diameter measured at CT angiography correlated with the length of hospital stay. CONCLUSION: In our cohort radiological parameters showed a significant correlation with clinical prognostic indices and scores, thus suggesting that a multidisciplinary approach is advisable in the evaluation of PE in COVID‐19 patients. Observational retrospective cohort study carried out at Luigi Sacco Hospital in Milan, the referral centre for highly transmissible diseases in Northern Italy. All patients admitted to COVID-19 specialised wards (Internal Medicine and ICU) between 28 March and 6 June 2020 were considered. The study adhered to the principles of the Declaration of Helsinki for medical research involving human subjects was approved by local IRB, and written informed consent was acquired from all subjects or their surrogates. Within the patients' list, we identified subjects hospitalised because of respiratory symptoms, with SARS-CoV-2 infection confirmed by real-time PCR on naso-pharyngeal swabs. Demographic-clinical characteristics and laboratory data at admission were extracted from the digital medical charts of our hospital. As per usual routine, locally defined clinical practice, to assess The presence of embolus in a segmental artery was scored 1 point, and emboli in the most proximal arterial level were scored a value equal to the number of segmental arteries arising distally. To provide additional information about the residual perfusion distal to the embolus, a weighting factor was assigned to each value, depending on the degree of vascular obstruction. This factor was equal to 0, when no thrombus was observed; 1, when partially occlusive thrombus was observed or 2, with total occlusion. Thus, the maximal CT obstruction index was 40 per patient. Isolated subsegmental embolus was considered as partially occluded segmental artery and was assigned a value of 1. The percentage of vascular obstruction was calculated by dividing the patient score by the maximal total score and by multiplying the result by 100. Therefore, the CT obstruction index can be expressed as follows: (n × d)/40 × 100, where n is the value of the proximal thrombus in the pulmonary arterial tree equal to the number of segmental branches arising distally (minimum, 1; maximum, 20), and d is the degree of obstruction (minimum, 0; maximum, 2). In case of discordance, a simultaneous reading to reach consensus was achieved. The Qanadli score provides an accurate but simple tool to quantify the presence, location and degree of arterial obstruction on CT images, able to highlight the burden of PE, thus distinguishing massive from submassive PE. 2, 3 The revised Geneva score (rGeneva) was calculated for all patients with DVT and PE and the Pulmonary Embolism Severity Index (PESI) score for all cases of PE. The rGeneva clinical prediction rule is useful to estimate the pretest probability of PE and stratify patients into low, intermediate or high risk based on medical history and physical exam alone. 4, 5 It aids in reducing unnecessary imaging studies by identifying low-risk patients who can be ruled out for PE with a negative D-dimer serum test. The PESI score is a risk stratification tool that has been validated to assess the probability of overall mortality and early outcome of patients with newly diagnosed PE. 4, [6] [7] [8] This can help physicians to make decisions on the appropriate management distinguishing patients who could potentially be treated as outpatients, from those who could benefit from higher levels of care. In the study period, 145 patients underwent chest CT angiographies because of respiratory symptoms, and 61 of them (42%) were positive for SARS-CoV-2. CT angiography revealed PE in 14 COVID-19 patients (23%). No differences were highlighted in interstitial pulmonary involvement between COVID-19 patients with and without PE. An example of CT finding is shown in Figure 1 . Data extraction from our hospital database revealed that last year we found 18 PE cases over 112 CT angiograms (16%) performed during the same time span. In one patient PE was massive and induced severe haemodynamic compromise, requiring thrombolysis and timely admission to ICU. Qanadli score had a significant correlation with PESI, D-dimer, serum high-sensitivity troponin, serum albumin, arterial pressure of oxygen to inspired fraction of oxygen ratio (pO 2 /FiO 2 ) and length of hospital stay ( Figure 2 ). PESI had a significant correlation with albumin (r = −0.655, 95%CI, −0.884 to −0.174, P = .013) and length of hospital stay (r = 0.728, 95%CI 0.307 to 0.911, P = .004). Furthermore, the ratio between the right and left ventricle diameter (V R /V L ) measured at CT scan 9 correlated with the length of hospital stay (r = 0.719, 95%CI, 0.189 to 0.924, P = .015). All studied patients survived. Our study found that the Qanadli score, a radiological index of Moreover, in accordance with previous studies, 10 Qanadli score as well as the CT estimation of the right ventricle overload, expressed as V R /V L ratio, correlated with the clinical impact of PE, as shown by the length of hospital stay. In our cohort, patients who developed VTE (either DVT or PE) had a pretest probability in the intermediate-high range, as also confirmed by the rGeneva score. The spectrum of mortality risk assessed by PESI score was wide, ranging from class I to class V risk strata, but no patients died in our cohort. The strong correlation between radiological scores, such as A limitation of our study is that many critically ill patients did not undergo CT angiography because of the marked disproportion between available resources and demand as well as risks related to transport for both patients themselves and healthcare professionals taking care of them during the surge of the epidemic. We plan to expand our cohort to provide results on the correlation between the Qanadli score and major outcomes, such as mortality and morbidity, as well as the rate of ICU admission. Our results strongly suggest that a multidisciplinary approach integrating radiological and clinical-laboratory findings is of pivotal importance in the evaluation and management of PE in COVID-19 patients. The authors have no conflicts of interest to declare. Data are available on reasonable request and after Institutional Ethical Committee authorisation. Maddalena Alessandra Wu https://orcid. org/0000-0003-1078-1632 Riccardo Colombo https://orcid.org/0000-0002-9616-803X COVID-19 and its implications for thrombosis and anticoagulation Can CT pulmonary angiography allow assessment of severity and prognosis in patients presenting with pulmonary embolism? What the radiologist needs to know New CT index to quantify arterial obstruction in pulmonary embolism: comparison with angiographic index and echocardiography ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the Comparison of the unstructured clinician gestalt, the wells score, and the revised Geneva score to estimate pretest probability for suspected pulmonary embolism The validation and reproducibility of the pulmonary embolism severity index Prognostic models in acute pulmonary embolism: a systematic review and meta-analysis Prognostic accuracy of clinical prediction rules for early post-pulmonary embolism all-cause mortality: a bivariate meta-analysis Prognostic value of computed tomography versus echocardiography derived right to left ventricular diameter ratio in acute pulmonary embolism Short-term mortality in acute pulmonary embolism: clot burden and signs of right heart dysfunction at CT pulmonary angiography Hypoalbuminemia in COVID-19: assessing the hypothesis for underlying pulmonary capillary leakage Neutrophil extracellular traps contribute to immunothrombosis in COVID-19 acute respiratory distress syndrome How to cite this article Clinical-radiological correlations in COVID-19-related venous thromboembolism: Preliminary results from a multidisciplinary study