Objective
The coronavirus disease of 2019 (COVID-19) due to SARS-CoV-2 infection has been found to cause an increased risk for venous thromboembolism (VTE). The aims of the study were to determine the frequency of VTE in critically ill patients with COVID-19 and its correlation with D-dimer levels and pharmacological prophylaxis.
Methods
This was a cohort study of critically ill patients due to COVID-19. All patients admitted to the intensive care unit on the same day of April 2020 were selected, regardless of length of stay, and a single bilateral venous duplex ultrasound in the lower extremities was performed up to 72 hours later. Pulmonary embolism (PE) was diagnosed with computed tomography angiography. Asymptomatic and symptomatic VTE were registered, including pre-screening in hospital VTE. Characteristics of patients, blood test results, doses of thromboprophylaxis received, VTE events, and mortality after seven day follow up were recorded.
Results
A total of 230 critically ill patients were studied. Median intensive care unit stay of these patients was 12 days (interquartile range [IQR] 5 – 19 days). After seven days of follow up, the frequency of patients with VTE, both symptomatic and asymptomatic, was 26.5% (95% confidence interval [CI] 21% – 32%) (69 events in 61 patients): 45 with DVT and 16 with PE (eight of them with concomitant DVT). Cumulative frequency of symptomatic VTE was 8.3% (95% CI 4.7% – 11.8%). D-dimer values ≥ 1 500 ng/mL were diagnostic for VTE, with a sensitivity of 80% and a specificity of 42%. During follow up after screening, six patients developed new VTE. Three of them developed a recurrence after a DVT diagnosed at screening, despite receiving therapeutic doses of heparin. Mortality rates at seven day follow up were the same for those with (6.6%) and without (5.3%) VTE.
Conclusion
Patients with severe COVID-19 infection are at high risk for VTE, and further new symptomatic VTE events and recurrence can occur despite anticoagulation. Prophylactic anticoagulation dosage may need to be increased in patients with a low risk of bleeding.
Patients undergoing hemodialysis have a lower survival rate than those who receive a kidney transplant. Mortality among hemodialysis patients is approximately 14.5% compared with 1.5% for transplant recipients. One of the exclusion criteria for renal transplant is severe iliac artery calcification. We performed an aortofemoral bypass in these patients to make them eligible for renal transplantation. Eleven patients were selected to receive an aortofemoral bypass. All had severe calcification of iliac arteries. Eight patients required a bypass from the thoracic aorta and two from the infrarenal level. Revascularization was successful in 10 patients. Patency was 100%. Surgery could not be performed in one owing to severe calcification of the femoral artery. One patient died owing to gastrointestinal bleeding. Two patients developed complications; one needed a splenectomy, and the other developed meningitis and paralytic ileus. To date, four patients have received transplants, and the viability of the transplanted kidney is good in all cases. Renal transplantation is the only method known to improve survival and quality of life for hemodialysis patients. We consider that if patients with severe iliac calcification are well informed of the morbidity and mortality risk of an aortic bypass, this intervention can be justified in this setting.
Since the outbreak of the COVID-19 pandemic, increasing evidence suggests that infected patients present a high incidence of thrombotic complications. We report a 67-year-old-woman admitted for severe acute respiratory syndrome coronavirus 2 infection. Chest CT images showed bilateral ground glass opacities, bilateral pulmonary embolism, right ventricular clot in transit and 2 thoracic aortic mural thrombus. Therapy was initiated with subcutaneous low-molecular-weight heparin, and the patient was discharged at 20 days asymptomatic. Complete resolution of the aortic thrombus was observed in a 1-month surveillance CT angiogram. Our case illustrates vascular complications in a COVID-19 patient and its effective treatment with anticoagulation.
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