Management of Spontaneous Bleeding in COVID-19 Inpatients: Is Embolization Always Needed?

Abstract

Background: critically ill patients with SARS-CoV-2 infection present a hypercoagulable condition. Anticoagulant therapy is currently recommended to reduce thrombotic risk, leading to potentially severe complications like spontaneous bleeding (SB). Percutaneous transcatheter arterial embolization (PTAE) can be life-saving in critical patients, in addition to medical therapy. We report a major COVID-19 Italian Research Hospital experience during the pandemic, with particular focus on indications and technique of embolization. Methods: We retrospectively included all subjects with SB and with a microbiologically confirmed SARS-CoV-2 infection, over one year of pandemic, selecting two different groups: (a) patients treated with PTAE and medical therapy; (b) patients treated only with medical therapy. Computed tomography (CT) scan findings, clinical conditions, and biological findings were collected. Results: 21/1075 patients presented soft tissue SB with an incidence of 1.95%. 10/21 patients were treated with PTAE and medical therapy with a 30-days survival of 70%. Arterial blush, contrast late enhancement, and dimensions at CT scan were found discriminating for the embolization (p < 0.05). Conclusions: PTAE is an important tool in severely ill, bleeding COVID-19 patients. The decision for PTAE of COVID-19 patients must be carefully weighted with particular attention paid to the clinical and biological condition, hematoma location and volume.

Spontaneous Retroperitoneal Hematoma Treated with Percutaneous Transarterial Embolization in COVID-19 Era: Diagnostic Findings and Procedural Outcome

“…The COVID-19-specific incidence of spontaneous muscular hematoma is actually unclear; Riu et al reported an incidence of 1.95% of soft-tissue spontaneous bleeding [ 20 ], higher than observed in general hospitalized patients receiving low-molecular-weight heparin (LMWH) for some reason. An explanation could be found in the physiopathology of SARS-CoV-2 infection related to endothelial damage [ 26 , 27 ].…”

“…SARS-CoV-2 infection carries a special condition of endotheliitis both for the viral infection of the cell and for the inflammatory response with subsequent cytokine storm, with the consequence of micro and macro thrombosis, as well as endothelial injury leading to micro-vessel fragility [ 20 ]. Endothelial damage was the reason why hospitalized patients were advised to treat hospitalized patients with high doses of LMWH (especially in the first wave, preventive doses are currently preferred), and why it is also difficult to achieve hemostasis in case of bleeding.…”

“…As mentioned before, despite the lack of specific guidelines on the treatment of spontaneous retroperitoneal hematoma, recent studies suggest that TAE plays an important role in the management of this condition, representing a safe and effective option for the treatment of spontaneous abdominal wall hematomas, including retroperitoneal hematomas [ 11 , 21 ]. Hemodynamically unstable patients can be also treated with TAE, due to its minimally invasive and quick therapeutic effect, compared to surgical treatment [ 20 ].…”

“…In the COVID-19 setting, PTAE can be considered an important tool in the treatment of spontaneous bleeding, including retroperitoneal hematoma, occurring in COVID-19-infected inpatients under anticoagulant therapy [ 20 ]. Lucatelli et al recently suggested the use of PTAE in COVID-19 patients, preferring it to conservative treatment and encouraging selective embolization even without signs of active bleeding [ 29 ].…”

“…This includes volume resuscitation, withdrawal or reversal of anticoagulation therapy, vasoactive drugs, and transfusions. In hemodynamically unstable patients or in the case of failure of conservative treatment, endovascular treatments such as digital subtraction angiography (DSA) and subsequent percutaneous transarterial embolization (PTAE) of the bleeding vessels have been recognized as a valid, effective, and potentially life-saving option in these patients, while open surgery is generally considered in very selective cases since the surgical removal of the hematoma may disturb the tamponade effects of the retroperitoneum, resulting in increased bleeding [ 19 , 20 , 21 ].…”