Author + information
- Received April 27, 2020
- Revision received May 27, 2020
- Accepted June 1, 2020
- Published online July 15, 2020.
- Bastien Woehl, MDa,∗ (, )
- Bree Lawson, MDb,
- Lucas Jambert, MDa,
- Jonathan Tousch, MDa,
- Afif Ghassani, MDc and
- Amer Hamade, MDa
- aService de médecine vasculaire, Hôpital Emile Muller de Mulhouse, Groupe Hospitalier de la Région de Mulhouse et Sud-Alsace, Mulhouse, France
- bService de cardiologie, Hôpital Emile Muller de Mulhouse Groupe Hospitalier de la Région de Mulhouse et Sud-Alsace, Mulhouse, France
- cService de chirurgie vasculaire, Hôpital Emile Muller de Mulhouse Groupe Hospitalier de la Région de Mulhouse et Sud-Alsace, Mulhouse, France
- ↵∗Address for correspondence:
Dr. Bastien Woehl, Hôpital Emile Muller GHRMSA, Service de médecine vasculaire, 20 rue du Dr. Laennec, 68100 Mulhouse, France.
Since the outbreak of the COVID-19 pandemic, increasing evidence suggests that infected patients present a high incidence of thrombotic complications. This report describes 4 cases of aortic thrombosis in patients admitted for COVID-19 infection between March 26 and April 12, 2020, in Mulhouse, France. (Level of Difficulty: Intermediate.)
Since the outbreak of the coronavirus-2019 (COVID-19) pandemic, increasing evidence suggests that infected patients present a high incidence of thrombotic complications such as deep vein thrombosis (1), pulmonary embolism (2), or microvascular thrombosis (3). All these data suggest the existence of a hypercoagulable state in patients with COVID-19 disease (4). This hypercoagulability induced by COVID-19 seems to be responsible for venous thromboembolic events but can also cause arterial complications.
• To recognize vascular complications among COVID-19 patients.
• To demonstrate the presence of aortic thrombosis in patients with COVID-19 disease.
This paper describes 4 cases of aortic thrombosis in patients admitted for severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection in the authors’ hospital in Mulhouse, France, between March 26 and April 12, 2020. Clinical characteristics and biological details are summarized in Table 1.
The first patient was a 64-year-old male with a history of Down syndrome (without congenital heart disease) admitted for hypoxemic pneumonia. COVID-19 disease was confirmed by reverse-transcriptase-polymerase-chain-reaction (RT-PCR) test. Computed tomography (CT) results showed bilateral ground glass opacities (20% lung injury) and a nonobstructive descending aortic thrombus formation (Figure 1). This patient was treated with therapeutic anticoagulation and presented no further complications. He was discharged home at day 6.
The second patient was a 68-year-old male with history of smoking, hypertension, coronary artery disease, and deep vein thrombosis (Table 1) who was admitted for acute bilateral lower limb ischemia. COVID-19 disease was confirmed by RT-PCR results. CT showed bilateral ground glass opacities (25% to 50% lung injury) as well as an obstructive thrombosis of the abdominal aorta and bilateral common iliac artery thromboses (Figure 2). An axillobifemoral bypass was performed, followed by therapeutic anticoagulation with good initial results. The patient died 7 days after surgery from a major hemorrhage.
The third patient was a 72-year-old male with history of hypertension, diabetes, and coronary artery disease (Table 1) who was admitted for hypoxic pneumonia. COVID-19 disease was confirmed by RT-PCR results, and CT showed bilateral ground glass opacities (25% to 50% lung injury). On day 14 after admission, the patient experienced acute ischemia of the right lower limb, and CT showed a nonobstructive abdominal aortic thrombosis as well as an obstructive right common iliac artery thrombosis (Figure 3). The patient was treated with therapeutic anticoagulation, and surgical thrombectomy was performed 7 days later with a good result.
The fourth patient was a 78-year-old male with a history of smoking, hypertension, cardiac hypertrophy, and pulmonary embolism (Table 1) who was admitted for hypoxic pneumonia. COVID-19 disease was confirmed by RT-PCR results, and CT showed bilateral ground glass opacities (25% to 50% lung injury). On day 7 after admission, the patient presented with abdominal pain. Abdominal CT showed a nonobstructive abdominal aortic thrombus formation and a right renal infarction consistent with a thrombosis of the right renal artery (Figure 4). Therapeutic anticoagulation was started. The patient presented with a cerebral infarction 2 days later and died.
To the authors’ knowledge, this is the first series of aortic thrombosis cases in COVID-19 patients to be published. Prognosis of patients hospitalized with COVID-19 disease is often determined by the extent of pulmonary lesions. However, vascular complications can also greatly affect outcome, as illustrated here. Many authors have recently demonstrated a strong link between COVID-19 infection and thromboembolism. The physiopathology has not yet been fully elucidated, but current data suggest the existence of a hypercoagulability state in patients with COVID-19 disease. A recent paper attributes this state “to excessive inflammation, platelet activation, endothelial dysfunction, and stasis” (5). Others have suggested that formation and polymerization of fibrin are responsible for this hypercoagulability (6). Therefore, recent recommendations insist on thromboprophylactic measures to prevent thromboembolism (4,7,8).
A recent publication found evidence of the presence of virus in endothelial cells (9). One explanation is that the angiotensin-converting enzyme 2 receptor that the virus uses to infect cells is widely expressed in endothelial cells. This causes endotheliitis, which could explain why COVID-19 patients seem prone to venous and arterial thrombosis. This paper (9) also underlines the fact that patients predisposed to endothelial lesions (hypertension, male sex, smoking, diabetes) could be more prone to infection of the endothelium induced by the virus. This was the case with the present series of patients who were all male, 75% had hypertension, 50% had a history of smoking, and 50% had a history of coronary artery disease. On the other hand, 2 of the 4 patients also had a history of pulmonary embolism or deep vein thrombosis, suggesting an individual predisposition. Finally, outcomes in COVID-19 patients affected by arterial thrombosis seem to be severe, as 50% of these patients died.
All authors have reported that they have no relationships relevant to the contents of this paper to disclose.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the JACC: Case Reports author instructions page.
- Abbreviations and Acronyms
- computed tomography
- reverse-transcriptase polymerase chain reaction
- severe acute respiratory syndrome-coronavirus-2
- Received April 27, 2020.
- Revision received May 27, 2020.
- Accepted June 1, 2020.
- 2020 The Authors
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