Published in:
01-05-2021 | COVID-19 | Letter to the Editor
Delayed catastrophic thrombotic events in young and asymptomatic post COVID-19 patients
Published in: Journal of Thrombosis and Thrombolysis | Issue 4/2021
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We read with interest the editorial “Anticipating the long-term cardiovascular effects of COVID-19 [1]” which featured COVID-19 end-organ thrombotic complications. COVID-19 associated hypercoagulability [2] and increased thromboembolism in COVID-19 has been well described [3]. While the editorial raised the key question about “potential long-term cardiovascular effects (of COVID-19)”, little is known about the post COVID-19 vascular complications. In response, we would like to highlight a series of catastrophic arterial events observed in post COVID-19 patients (Table 1), echoing the Editor’s concerns of post-infectious vasculopathy.
Table 1
Four cases of post COVID-19 acute arterial thromboses
|
No
|
Age
|
Ethnic group
|
Sex
|
Presentation
|
Arterial events and co-morbidities
|
Imaging
|
SARS-CoV total antibody
|
SARS-CoV PCR
|
Date of arterial event
|
Days from positive serology to thrombosis
|
Treatment
|
Initial haemostatic assessment
|
Repeat haemostatic assessment
|
Current status
|
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
1
|
38
|
Indian
|
M
|
Fall with Acute right sided weakness
Global aphasia NIHSS: 23
|
Acute left MCA infarct
No comorbidities
|
MRI brain
Diffuse loss of grey-white differentiation and restricted diffusion involving the left fronto-parieto-temporal lobes and left basal ganglia
|
Positive × 1
27 May
|
Not tested
|
7 July
|
41 days
|
1.IV rtPA
2.Endovascular therapy
3. Aspirin
|
PT 13.5
APTT 26.4
D-dimer 3.20
Fibrinogen 2.7
vWF 260%
Factor VIII NA
Platelets 227
|
22 July > 3 Aug > 7 Oct
PT 14.3 > 13.5 > 13.3
APTT 28.8 > 31.1 > 27.1
D-dimer 3.39 > 1.22 > 0.46
Fibrinogen 7.5 > 5.6 > 3.3
vWF 272% > 240% > 186%
Factor VIII 208% (7 Oct)
Platelets 583 > 369 > 256
|
71 days in Rehabilitation
|
|
2
|
39
|
Indian
|
M
|
Acute right sided weakness
Global aphasia
NIHSS: 25
|
Left MCA and PCA infarct
Pulmonary Embolism
Infrarenal aortic thrombus
Newly diagnosed DM
|
MRI brain
Large area of restricted diffusion is noted in the left fronto-parieto-temporal lobes, the left occipital and posterior medial temporal lobes
CT pulmonary angiogram
Thrombi seen in the right lower lobe, left upper lobe, left lower lobar, segmental and segmental branches. The main pulmonary arteries have no filling defects seen
CT abdomen/pelvis
Eccentric mural thrombus in the infrarenal aorta
|
Positive × 2
21 May
14 Aug
|
Negative × 2
20 Aug
21 Aug
|
5 Aug
|
76 days
|
1.Thrombectomy
2.Craniectomy
3.Low molecular weight heparin with bridging to warfarin
|
PT 13.7
APTT 26.6
D-dimer 3.55
Fibrinogen 5.8
vWF 226%
Factor VIII 238%
Platelets 301
|
30 Sept
PT 30.9
APTT 38.4
Fibrinogen 4.7
vWF 153%
Factor VIII 217%
Platelets 256
|
30 days in Rehabilitation
|
|
3
|
49
|
Indian
|
M
|
Left acute painful lower limb
|
Left acute ischaemic limb
Infrarenal aortic thrombus
No comorbidities
|
CT angiography
Occlusion of the left popliteal artery extending to tibioperoneal trunk and into the origins of the ATA, PTA and peroneal arteries. Aetiology is likely an embolus from the distal aorta/left common iliac artery
|
Positive × 1
3 June
|
Negative × 3
12 May
21 May
2 Sept
|
2 Sept
|
91 days
|
1.Thrombectomy
2.IV Heparin followed by Rivaroxaban
|
PT 13.1
APTT 26.7
D-dimer 0.42
Fibrinogen NA
Factor VIII 216%
vWF 161%
Platelets 256
|
Not assessed yet as thrombotic event was recent
|
Discharged Home Well
|
|
4
|
38
|
Indian
|
M
|
Chest pain and sudden collapse
|
ST-Elevation myocardial infarction
No comorbidities
|
Coronary angiogram
1. Dominance—Right-dominant
2. LM—Free of significant disease
3. LAD—Ostial LAD occluded
4. LCx—Normal
5. Ramus intermedius ( RI)—Normal
6. RCA – Normal
|
Positive × 1
9 July
Negative × 1
29 May
|
Negative × 4
24 June
27 Sept
28 Sept
3 Oct
|
27 Sept
|
80 days
|
1.PCI with drug eluting stent to LAD
2. Intraaortic balloon pump
3. Heparin
4. Aspirin
5. Ticagrelor
|
PT 15.7
APTT 31.8
D-dimer 4.11
Fibrinogen 5.2
vWF 374%
Platelets 156
|
Not assessed yet as thrombotic event was recent
|
Admitted to cardiac intensive care unit
|