key: cord-1028284-4z55iu1f
authors: Kasirajan, Karthikeshwar
title: Acute Upper Extremity Ischemia and Symptomatic Popliteal Artery Aneurysm Secondary to Covid19
date: 2021-03-02
journal: J Vasc Surg Cases Innov Tech
DOI: 10.1016/j.jvscit.2021.02.009
sha: 4c841b0921255cafea1ddfcc3a3e087e7886b2e0
doc_id: 1028284
cord_uid: 4z55iu1f

One patient presented with an acute right upper extremity ischemia (axillary artery thrombosis) and the other with a symptomatic popliteal artery aneurysm (7.5x7.2-cm). Both patients tested positive for Covid-19 but had no systemic symptoms. The patients were successfully managed using percutaneous techniques and subsequently discharged on oral anticoagulation. A review of the pathogenesis of SARS-CoV-2 related arterial thrombosis and aneurysmal disease are discussed.

The World Health Organization (WHO) declared Coronavirus disease-2019 (Covid-19), a viral 1 disease caused by sever acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), as a 2 pandemic on March 11 th, 2020. 1 Although globally the incidence has exceeded 22 million at the 3 time of writing this manuscript, the need for vascular surgical interventions specific to Covid-19 4 has not exploded.. The author reviews the current understanding of the pathogenesis of 5 thrombosis in Covid -19 patients. Additionally, it is now recognized that the Angiotensin 6 converting enzyme 2 (ACE2)/angiotensin 1-7 (Ang1-7)/Mas axis is downregulated by SARS-7 CoV-2. 2 The downregulation of ACE2 and its role in the pathogenesis of aneurysms is also 8 discussed. A written consent was obtained from both patients to use imaging for publication. Labs were all normal except for an elevated c-reactive protein, d-dimer, and slightly diminished 22 platelet count (Table I) . Treatment was undertaken using conscious sedation. Contralateral 23 J o u r n a l P r e -p r o o f femoral access was obtained and the aneurysm was excluded using a 8-mm X 250-mm Viabahn 1 (W.L.Gore, Flagstff, AZ) placed through a 7Fr sheath (Figure 1a,b) . The next day, the patient 2 continued to have palpable pedal pulses with no pulsation over the popliteal aneurysm and he 3 was discharged home on apixaban 5-mg twice a day. At the 1-month follow-up, his knee pain 4 has resolved, and Duplex imaging demonstrated aneurysm thrombosis with graft patency. Size of 5 the aneurysm was stable compared to prior CT images. Currently, at 6 months, patient 6 symptoms have resolved, and he is able to flex his knee to status prior to initial presentation. Additionally, patient has also noticed that he has fewer visible varicose veins compared to 8 before. The new onset pain most likely represented an impending rupture. The unusual event was the 8 inability to bend the knee over the last 3 days. Patient was an active male, used to working in the 9 garden and was accustomed to having to work with his knees flexed to >90 degrees on most 10 days. This points to a rapid increase in aneurysm size over the last few days prior to current 11 presentation.

The rapid increase in size of the aneurysm may theoretically have been linked to his Covid-19 13 infection. No other cause for pain or inability to flex the knee was noted in this patient. 14 Furthermore, following aneurysm exclusion at 6 months patients pain symptoms have resolved.

These factors taken together suggest that the initial presentation was most likely related to rapid in Covid-19 patients, and mortality and thrombotic events has been associated with higher 20 levels. 9 Both our patients had elevated CRP and D-dimer levels with a much more pronounced 21 elevation in the patient with the axillary artery thrombosis (Table I) Fig 3. Pathogenesis of SARS-Cov-2 and its effect on the Angiotensin pathway by down regulating the ACE2 is demonstrated. The subsequent effect on the Angiotensin system resulting in increased activation of the proinflammatory AT1R pathway to potentiate aneurysm growth is also illustrated. 

World Health Organization Coronavirus disease