key: cord-0919281-p63reigt
authors: Hamilton, Kirsten Victoria; Hussey, Keith Kelso
title: Intra-arterial thrombosis associated with COVID-19
date: 2020-05-17
journal: J Vasc Surg
DOI: 10.1016/j.jvs.2020.05.019
sha: c87cd0f30250a3535c20f0dd60e06f9e6a6e1879
doc_id: 919281
cord_uid: p63reigt

nan

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a global pandemic. The development of an acquired thrombophilia with activation of the coagulation cascade in response to the inflammatory process has been described. 1 SARS-CoV-2 appears to have an affinity for angiotensin-converting enzyme 2 receptors that seem to be downregulated, which may drive the proinflammatory/prothrombotic consequences. 2 As this is a novel illness, there has been limited opportunity to understand and to investigate the effect of SARS-CoV-2. In severe disease, there appears to be elevation of D-dimer levels. Prolongation of prothrombin time and activated partial thromboplastin time seems to be associated with an increased risk of acute respiratory distress syndrome and death. 3 The development of disseminated intravascular coagulation appears to be common in nonsurvivors. 4 There appears to be an increased risk of pulmonary thromboembolic events in ventilated patients with SARS-CoV-2, despite the administration of lowmolecular-weight heparin prophylaxis. In a small series of minimally invasive autopsies, a significant proportion of patients were found to have small fibrinous thrombi in pulmonary arterioles. 1 Similar data have been described across Europe with revision of low-molecularweight heparin prophylaxis dosing. As well as the described pulmonary thrombotic complications, a series of early circuit occlusions has been encountered in patients on hemofiltration as a consequence of multiple organ dysfunction syndrome from SARS-CoV-2.

Recently, a small number of patients have presented with systemic intra-arterial thrombosis and a diagnosis of SARS-CoV-2. There is some evidence to suggest that this may occur, with a small series reporting ischemic strokes in patients in intensive care units. 5 In our experience, patients presenting with limb-threatening ischemia and SARS-CoV-2 have had no other clear reason for development of intra-arterial thrombosis. Management has been dictated primarily by the severity of the organ dysfunction. A conservative approach with the prescription of therapeutic low-molecular-weight-heparin with subsequent conversion to a direct-acting oral anticoagulant has been an effective strategy.

Vascular surgeons have to recognize the potential for limb-and life-threatening arterial occlusion events in patients with SARS-CoV-2. Further research is required to try to elucidate the mechanisms by which this disease process activates the coagulation cascade.

Pathological evidence of pulmonary thrombotic phenomena in severe COVID-19

The science underlying COVID-19: implications for the cardiovascular system

Hematological findings and complications of COVID-19

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

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