Staged acute mesenteric and peripheral ischemia treatment in COVID-19 patient: Case report

Abstract

Introduction COVID-19 is an infectious disease that has been associated not only with respiratory complications. The COVID-19 disease includes, also damage to other organ systems as well as coagulopathy. The present report describes a case of COVID-19 presenting with acute mesenteric ischemia (AMI) and subsequent acute limb ischemia (ALI). Presentation of case An 84-years old hospitalized female patient presenting diabetes and recent COVID-19 reported acute onset of abdominal pain and typical findings of AMI. The CT-angiography confirmed the AMI secondary to a superior mesenteric artery (SMA) occlusion. The patient was managed through an endovascular approach using a SMA mechanical thrombectomy and stenting with a good result. Discussion Treatment of this life-threatening condition includes surgical resection of the necrotic bowel, restoration of blood flow to the ischemic intestine and supportive measure - gastrointestinal decompression, fluid resuscitation, hemodynamic support. Endovascular management of AMI is preferred over the standard surgical approach due to a reduced mortality and morbidity rates. Imaging findings of intestinal necrosis, however, represent an indication for AMI surgical treatment with explorative laparotomy. Different endovascular solutions have been employed to address AMI including mechanical thrombectomy, local thrombolysis, and PTA-stenting. Conclusion COVID-19 clinical presentation can be atypical, including gastrointestinal symptoms. If a first embolic event occurs, an aggressive anticoagulation treatment could be inefficient to reduce the risk of subsequent embolization events. The limited life expectancy of such revascularization procedures should orientate towards less invasive treatments.

Acute Mesenteric Ischemia in COVID-19 Patients

“…We also identified 30 case reports or case series [ 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 ] presenting 34 cases of acute bowel ischemia in patients positive for SARS-CoV-2 infection in different clinical settings. 8 cases were previously hospitalized for COVID-19 pneumonia and under anticoagulant medication ( Table 2 ).…”

Bowel ischemia in COVID‐19: A systematic review

“…Supportive and conservative therapy includes gastric decompression, fluid resuscitation, and hemodynamic support. 44 , 45 Also, early diagnosis and systemic thrombolysis have been shown to produce better outcomes in terms of bowel salvage. 44 , 45 …”

“… 44 , 45 Also, early diagnosis and systemic thrombolysis have been shown to produce better outcomes in terms of bowel salvage. 44 , 45 …”

“…Supportive and conservative therapy includes gastric decompression, fluid resuscitation, and hemodynamic support. 44,45 Also, early diagnosis and systemic thrombolysis have been shown to produce better outcomes in terms of bowel salvage. 44,45 In terms of surgical interventions, exploratory laparotomy followed by bowel resection was often sought because of the acute presentation of the case.…”

Acute Mesenteric Ischemia as an Early Complication of COVID-19

“…Treatment includes early fluid resuscitation, use of broad-spectrum antibiotics, and surgical resection of the necrotic bowel, along with restoration of blood supply. Hemodynamic resuscitation and gastrointestinal decompression are often required [ 11 - 12 ]. Emergency laparotomy must be performed immediately after the onset of abdominal pain to achieve a favorable outcome [ 11 ].…”