Limb Ischemia due to Extensive Arterial Thrombosis in the Absence of Venous Occlusion as an Unusual Complication of Critical Illness from COVID-19

Abstract

There is increasing evidence of a link between the coronavirus disease 2019 (COVID-19) and venous and arterial thrombotic events. Here, we report a 60-year-old male patient with severe COVID-19 who developed extensive arterial thromboses and limb ischemia despite being on therapeutic-dose anticoagulation. While the exact mechanism for such events is unknown, our report highlights the importance of maintaining a high degree of suspicion in critically ill patients. Further research should focus on the mechanistic pathways along with the optimal anticoagulation and/or antithrombotic strategy.

Aortic thrombosis after DVT and PE in a young COVID-19 patient

“…According to the International Society on Thrombosis and Haemostasis, all hospitalized SARS-CoV-2 infected patients should get prophylactic anticoagulation therapy ( 15 ) , particularly those with risk factors such as smoking, physical inactivity, hypertension, diabetes, obesity, cardiovascular diseases, male gender, and older age ( 16 ) . However, it is being more commonly reported in existing literature as well as in our clinical experience that despite administration of thromboprophylaxis thrombotic events may still occur ( 4 , 17 , 18 ) . Extensive clinical trials are needed to clarify the best ways of preventing and managing thrombotic complications during COVID-19.…”

Risk Factors, Clinical Presentation, Therapeutic Trends, and Outcomes in Arterial Thrombosis Complicating Unvaccinated COVID-19 Patients: A Systematic Review

“… 39 Notably, before vaccines were available for primary prevention in hospitalized COVID-19 patients, recommendations did not differ from non–COVID-19 in-hospital patients. 40 …”

“…Despite some evidence pointing towards the benefit of higher D-dimer measurements, there are no recommendations for using coagulopathy markers to guide treatment. 40 Consequently, we do not have guidance for AT primary prevention or measures for early detection in the broad clinical spectrum of unvaccinated COVID-19 patients. Antithrombotic and anti-inflammatory drugs remain the cornerstone for COVID-19 disease and COVID-19-induced thrombosis.…”

“…39 Notably, before vaccines were available for primary prevention in hospitalized COVID-19 patients, recommendations did not differ from non-COVID-19 in-hospital patients. 40 Furthermore, the National Institute of Health guidelines do not recommend anticoagulation prophylaxis to prevent AT outside the usual standard of care for non-COVID-19 patients. 40 D-dimer demonstrated a consistently elevated pattern in COVID-19 patients with thrombosis, while platelet count, fibrinogen levels, and prothrombin time (PT) vary from standard to high levels.…”

“…40 Furthermore, the National Institute of Health guidelines do not recommend anticoagulation prophylaxis to prevent AT outside the usual standard of care for non-COVID-19 patients. 40 D-dimer demonstrated a consistently elevated pattern in COVID-19 patients with thrombosis, while platelet count, fibrinogen levels, and prothrombin time (PT) vary from standard to high levels. 28 Our cohort displayed a similar pattern, with 118 (53.6%) patients with D-dimer >1000 ng/ mL, and only 16 (7.3%), 26 (11.8%), 35 (16.0%) with platelet count >400 10 9 /L, prothrombin time >13.5 s, and fibrinogen levels >400 mg/dL, respectively.…”