Arterial thromboembolic complications in COVID‐19 in low‐risk patients despite prophylaxis

Griffin, Daniel O.; Jensen, Alexandra; Khan, Mushmoom; Chin, Jessica; Chin, Kelly; Parnell, Ryan; Awwad, Christopher; Patel, Darshan P.

doi:10.1111/bjh.16792

Cited by 45 publications

(44 citation statements)

References 10 publications

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“…It is unclear whether the same mechanisms are involved in venous as in arterial clots. Arterial clots in COVID-19 patients removed at the time of surgery [28] have been consistent with being platelet-rich which suggests that anti-platelet agents may have a role to play in preventing arterial complications.…”

Section: Discussionmentioning

confidence: 79%

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Thrombotic and haemorrhagic complications in critically ill patients with COVID-19: a multicentre observational study

et al. 2020

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Background Optimal prophylactic and therapeutic management of thromboembolic disease in patients with COVID-19 remains a major challenge for clinicians. The aim of this study was to define the incidence of thrombotic and haemorrhagic complications in critically ill patients with COVID-19. In addition, we sought to characterise coagulation profiles using thromboelastography and explore possible biological differences between patients with and without thrombotic complications. Methods We conducted a multicentre retrospective observational study evaluating all the COVID-19 patients received in four intensive care units (ICUs) of four tertiary hospitals in the UK between March 15, 2020, and May 05, 2020. Clinical characteristics, laboratory data, thromboelastography profiles and clinical outcome data were evaluated between patients with and without thrombotic complications. Results A total of 187 patients were included. Their median (interquartile (IQR)) age was 57 (49–64) years and 124 (66.3%) patients were male. Eighty-one (43.3%) patients experienced one or more clinically relevant thrombotic complications, which were mainly pulmonary emboli (n = 42 (22.5%)). Arterial embolic complications were reported in 25 (13.3%) patients. ICU length of stay was longer in patients with thrombotic complications when compared with those without. Fifteen (8.0%) patients experienced haemorrhagic complications, of which nine (4.8%) were classified as major bleeding. Thromboelastography demonstrated a hypercoagulable profile in patients tested but lacked discriminatory value between those with and without thrombotic complications. Patients who experienced thrombotic complications had higher D-dimer, ferritin, troponin and white cell count levels at ICU admission compared with those that did not. Conclusion Critically ill patients with COVID-19 experience high rates of venous and arterial thrombotic complications. The rates of bleeding may be higher than previously reported and re-iterate the need for randomised trials to better understand the risk-benefit ratio of different anticoagulation strategies. Graphical abstract

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Section: Discussionmentioning

confidence: 79%

“…Helms et al only reported four (2.6%) cases in a cohort study of 150 COVID-19 ICU patients [7]. Arterial complications may result in major morbidity as highlighted in recent case reports [27,28]. It is unclear whether the same mechanisms are involved in venous as in arterial clots.…”

Section: Discussionmentioning

confidence: 99%

Thrombotic and haemorrhagic complications in critically ill patients with COVID-19: a multicentre observational study

et al. 2020

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“…Interestingly Oxley et al noted an increased occurrence of younger SARS CoV2 virus-infected patients with no significant traditional risk factors for AIS, presenting with large vessel occlusion (6). Putative mechanisms suggested as inducing AIS in association with SARS CoV2 have included systemic inflammation, inflammatory cytokine storm, hyper-coagulability, and imbalances in the classical and alternative Renin Angiotensin System (RAS) in relation to SARS-CoV-2 spike glycoprotein-ACE2 binding related molecular mechanisms (3,(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)). The RAS system comprises both a plasmabased RAS regulating cardiovascular system and tissue-based RAS regulating long term changes via a complex hormonal system, endocrine, paracrine, and autocrine in action.…”

Section: Introductionmentioning

confidence: 99%

Acute Ischemic Stroke in COVID-19: A Case-Based Systematic Review

2020

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Corona virus disease (COVID-19), caused by the severe acute respiratory syndrome coronavirus2 (SARS-CoV-2) is recognized as a global pandemic by WHO 2020 with 5,934 936 infections, 367,166 deaths and affecting over 200 countries as of 30th May 2020. Acute Ischemic Stroke (AIS) in brain is also emerging as an important neurovascular/neurological complication of COVID-19, associated with extreme immune responses leading to dysregulated coagulation system and generalized thrombo-embolic status and increased risk of AIS especially among usually less vulnerable younger adults in this cohort. Thus, in early June 2020, we aimed to review the clinical data on all published cases of COVID-19 and concomitant AIS, with a view to understanding the pertinent clinical, laboratory and imaging features. The neutrophil-lymphocyte ratio (NLR) at time of hospital admission for COVID infection correlates positively with the duration of time before onset of clinical features of AIS. Higher NLR, C-Reactive protein, serum ferritin, D-dimer and fibrinogen levels are associated with poor prognosis of AIS in COVID-19 with 75% of patients dying or being severely disabled at present. Currently it is too early to comment on the long-term outcomes for survivors.

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“…It is possible that the cause of his acute arterial thrombosis was DIC, but it is also possible that COVID-19 contributed to his hypercoagulability by a yet unknown mechanism. The prevalence of these arterial and venous thromboses in COVID-19 is well documented in the literature [ 1 - 3 , 5 - 8 ].…”

Section: Discussionmentioning

confidence: 99%

“…A retrospective study of venous thromboembolism (VTE) incidence in 26 patients with COVID-19 by Llitjos et al demonstrated that 100% (n = 8) of those on prophylactic dose anticoagulation, and 56% (n = 10) of those on therapeutic dose anticoagulation experienced VTE [ 6 ]. A case report by Griffen et al described an individual on therapeutic enoxaparin who also developed acute ischemia of the lower limb [ 8 ]. The risk of thromboembolic events and the sheer magnitude of COVID-19-associated admissions have prompted many hospitals to establish novel protocols with which these individuals are provided anticoagulation at increased or even therapeutic doses compared to the more common prophylactic dose.…”

Section: Discussionmentioning

confidence: 99%

COVID-19-Associated Acute Limb Ischemia in a Patient on Therapeutic Anticoagulation

Gubitosa¹,

Xu²,

Ahmed³

et al. 2020

Cureus

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Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been found to cause multiple complications across several organ systems in patterns not typically observed in previous iterations of the virus. Hemostatic mechanisms have been noted to be significantly altered in particular, resulting in a disseminated intravascular coagulation (DIC)-like picture with elements of coagulopathy as well as hypercoagulability. A 65-year-old man with hypertension, hyperlipidemia, prior tobacco use, chronic kidney disease, and diabetes presented from a correctional facility with hypoxia. The diagnosis of COVID-19 was confirmed. With his elevated D-dimer of >7,955 ng/mL (reference: 90-500 ng/mL) in the setting of COVID-19 and hypoxia, he was empirically started on therapeutic anticoagulation with enoxaparin. His oxygen requirements increased, mental status deteriorated, and platelets began falling, raising concern for heparin-induced thrombocytopenia versus DIC. Heparin products were discontinued in favor of a direct oral anticoagulant. He later became obtunded and unable to tolerate oral medications. Fondaparinux was initiated. Two days later, he was found to have acute limb ischemia of the right lower extremity. He underwent surgical thrombectomy but required an above-the-knee amputation the following day. Shortly after he died secondary to hypoxic respiratory failure. This case highlights the derangement of hemostatic mechanisms seen prominently in COVID-19 infection and raises questions as to appropriate anticoagulant choices to adequately prevent thrombosis. Thorough physical exams should be performed on all patients with COVID-19, taking into account this documented hypercoagulability. Further investigation is warranted into the use of heparin products as the anticoagulant of choice in these patients given observed deficiencies of antithrombin III (ATIII).

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Arterial thromboembolic complications in COVID‐19 in low‐risk patients despite prophylaxis

Cited by 45 publications

References 10 publications

Thrombotic and haemorrhagic complications in critically ill patients with COVID-19: a multicentre observational study

Thrombotic and haemorrhagic complications in critically ill patients with COVID-19: a multicentre observational study

Acute Ischemic Stroke in COVID-19: A Case-Based Systematic Review

COVID-19-Associated Acute Limb Ischemia in a Patient on Therapeutic Anticoagulation

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