A COVID-19 patient with recurrent acute limb ischaemia despite two successive types of therapeutic dose anticoagulation and thrombolysis

Abstract

COVID-19 is caused by the SARS-CoV-2, and its presentation ranges from mild upper respiratory illness to critical disease including acute respiratory distress syndrome and multiorgan dysfunction. While it was initially believed to primarily target the respiratory system, numerous studies have demonstrated it to cause a hypercoagulable state that predisposes to arterial and venous thrombosis. We present a case where a patient with COVID-19 developed acute lower limb ischaemia due to arterial thrombosis in the setting of full-dose enoxaparin, followed by heparin infusion protocol. The patient developed recurrent ischaemia despite thrombolysis in addition to anticoagulation, and eventually required open thrombectomy before making a full recovery.

Diagnóstico e manejo de isquemia aguda de membro em paciente pós infecção viral por covid-19: série de casos

“…14 Reports have been published describing different clinical presentations and management of these events, such as ischemic stroke, 15 deep venous thrombosis (DVT), mesenteric ischemia, 16 thrombosis of the abdominal aorta and common iliac artery bilaterally, 17 arterial thrombosis limbs in isolation, 18 , 19 and even association with autoimmune diseases. 20 Teng et al 21 described the case of a patient who had two episodes of acute arterial occlusion of the right lower limb during the infection and even using anticoagulant therapy (due to the patient having developed pulmonary embolism). 21 Management of arterial events includes surgical treatment with thromboembolectomy, supplemented or not by adjuvant therapy with intra-arterial fibrinolytics and/or systemic heparinization.…”

“… 20 Teng et al 21 described the case of a patient who had two episodes of acute arterial occlusion of the right lower limb during the infection and even using anticoagulant therapy (due to the patient having developed pulmonary embolism). 21 Management of arterial events includes surgical treatment with thromboembolectomy, supplemented or not by adjuvant therapy with intra-arterial fibrinolytics and/or systemic heparinization. 22 Rosa et al 23 described cases of upper limb ischemia diagnosed during acute presentation of SARS-CoV-2 in which a combination of heparin and corticoid with alprostadil was used, with varying outcomes depending on the severity of the cases.…”

“…Já foram publicados relatos de diferentes apresentações clínicas e condutas frente a esses eventos, como acidente vascular encefálico isquêmico (AVEi) 15 , trombose venosa profunda (TVP), isquemia mesentérica 16 , trombose de aorta abdominal e de artéria ilíaca comum bilateralmente 17 , trombose arterial de membros isoladamente 18 , 19 e até mesmo associação com doenças autoimunes 20 . Teng et al 21 descreveram o caso de um paciente que, durante a infecção e mesmo em uso de terapia anticoagulante (pois o paciente havia desenvolvido embolia pulmonar), apresentou dois episódios de oclusão arterial aguda em membro inferior direito 21 . Entre os eventos arteriais, as condutas têm sido relatadas com a terapêutica cirúrgica pela tromboembolectomia, complementada ou não por terapia adjuvante com fibrinolítico intra-arterial e/ou heparinização sistêmica 22 .…”