Table of Contents  
CASE SERIES
Year : 2022  |  Volume : 9  |  Issue : 2  |  Page : 188-190

A case series of lower-limb ischemia due to thromboembolic complication of COVID-19


Department of Surgery, K. J. Somaiya Medical College, Mumbai, Maharashtra, India

Date of Submission17-Sep-2021
Date of Acceptance15-Nov-2021
Date of Web Publication13-Jun-2022

Correspondence Address:
Aashik Shetty
Department of Surgery, K. J. Somaiya Medical College, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_96_21

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  Abstract 


The World Health Organization was notified on December 31, 2019, that a cluster of pneumonia patients with an unknown origin had been discovered in Wuhan City, Hubei Province, China. Severe acute respiratory syndrome coronavirus 2 caused the pneumonia (coronavirus disease 2019 [COVID-19]). Fever, dry cough, and shortness of breath are among the most prevalent symptoms described by COVID-19 patients. In this case series, we discuss three cases of patients presenting with deep vein thrombosis for which they underwent inferior vena cava filter placement with thrombolysis and mechanical thrombectomy. These cases were unusual as they belong to the moderate category of COVID rather than severe category which commonly presents with coagulopathy.

Keywords: Coagulopathy, coronavirus disease 2019, thrombectomy, thrombotic events


How to cite this article:
Madhukar KP, Bhuta M, Shenoy C, Shetty A, Shetty T. A case series of lower-limb ischemia due to thromboembolic complication of COVID-19. Indian J Vasc Endovasc Surg 2022;9:188-90

How to cite this URL:
Madhukar KP, Bhuta M, Shenoy C, Shetty A, Shetty T. A case series of lower-limb ischemia due to thromboembolic complication of COVID-19. Indian J Vasc Endovasc Surg [serial online] 2022 [cited 2022 Jul 3];9:188-90. Available from: https://www.indjvascsurg.org/text.asp?2022/9/2/188/347262




  Introduction Top


Severe acute respiratory syndrome-associated coronavirus-2 (SARS-CoV-2) is linked to a hypercoagulable condition, deep vein thrombosis (DVT), and pulmonary embolism in 16%–27% of cases.[1] Fever and dyspnea are the most typical symptoms in coronavirus disease 2019 (COVID-19), which are comparable to those of a regular cold. The disease is highly contagious with high mortality rate throughout the globe. Spike glycoprotein binds to enzyme 2 angiotensin-converting enzymes (ACE2), sialic acid receptor, transmembrane 2 serine protease (TMPRSS2), and extracellular slow cell matrix metalloproteinase which allows SARS-CoV-2 to enter host cells (CD147).[2],[3],[4],[5] Endothelial dysfunction is aggravated by hypoxia, which induces thrombosis by increasing blood viscosity and the signaling pathway associated with it. In this case series, we present the characteristics and outcomes of three cases of inferior vena cava (IVC) filter placement performed in patients presenting with COVID-19-related iliocaval thrombosis.[6]


  Case Reports Top


Case 1

A 43-year-old man [[Table 1], Case 1] had fever for 1 week with upper respiratory tract illness and was found to be COVID-19 positive through reverse transcription-polymerase chain reaction (RT-PCR). He did not have any other symptoms of the viral disease and was treated in home isolation for 2 weeks. He complained of pain, numbness, and swelling of the right lower limb past 4 days for which he visited the hospital. There was no history of diabetes, hypertension, or other comorbidities. On clinical examination, there were diffuse tenderness from below knee and raised temperature in the tender region with Homans' sign positive. The patient was otherwise normal with stable findings on examination. He was investigated with Doppler and diagnosed with acute DVT of the right lower limb till right common iliac vein (CIV). Blood investigations revealed raised D-dimer and white blood cells (WBCs) (14,000) for which he was given a course of antibiotics and a raised serum creatinine of 1. Digital subtraction angiography (DSA) revealed complete thrombosis till right CIV. He had an IVC filter placement with thrombolysis and mechanical thrombectomy using 5 mg Actilyse. Blood flow was completely restored in the affected vessels following the procedure. He was put on tablet rivaroxaban 15 mg for 3 weeks twice a day followed by 20 mg twice a day for 3 months. His symptoms came down postoperatively and had a full recovery within 5 days.
Table 1: D-Dimer levels and computed tomography score in the patients

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Case 2

A 43-year-old-woman [[Table 1], Case 2] had fever for 1 week with upper respiratory tract illness and was found to be COVID-19 positive through RT-PCR. She did not have any other symptoms of the viral disease and was treated in home isolation for 2 weeks. She complained of pain, numbness, and swelling of the left lower limb past 8 days for which he visited the hospital. The patient is a known diabetic for 6 months and on regular oral hypoglycemic agents. On clinical examination, there were diffuse tenderness from below knee and raised temperature in the tender region with Homans' sign positive. The patient was otherwise normal with stable findings on examination. She was investigated with Doppler and diagnosed with acute DVT of the left lower limb till left CIV. Blood investigations revealed raised D-dimer and WBCs (14,000) for which she was given a course of antibiotics and a raised serum creatinine of 1.2. DSA revealed complete thrombosis till left CIV with CIV stenosis. She had an IVC filter placement with thrombolysis and mechanical thrombectomy using 5 mg Actilyse with balloon venoplasty of CIV stenosis. Blood flow was completely restored in the affected vessel following the procedure. She was put on tablet rivaroxaban 15 mg for 3 weeks twice a day followed by 20 mg twice a day for 3 months. There were no adverse effects or complications following the procedure, and she did not need any modification of intervention. Her symptoms came down postoperatively and had a full recovery within 5 days.

Case 3

A 62-year-old-man [[Table 1], Case 3] had fever for 1 week with upper respiratory tract illness and was found to be COVID-19 positive through RT-PCR. He did not have any other symptoms of the viral disease and was treated in home isolation for 2 weeks. He complained of pain, numbness, and swelling of the left lower limb past 6 days for which he visited the hospital. The patient is a known diabetic for 6 years and hypertensive for 10 years on regular oral hypoglycemic agents and antihypertensive drugs. On clinical examination, there were diffuse tenderness from below knee and raised temperature in the tender region with Homans' sign positive. The patient was otherwise normal with stable findings on examination. He was investigated with Doppler and diagnosed with acute DVT of the left lower limb till left CIV. Blood investigations revealed raised D-dimer and WBCs (14,000) for which he was given a course of antibiotics and a raised serum creatinine of 1.5. DSA revealed complete thrombosis till left CIV with CIV stenosis. He had an IVC filter placement with thrombolysis and mechanical thrombectomy using 5 mg Actilyse with balloon venoplasty of CIV stenosis. Blood flow was completely restored in the affected vessel following the procedure. He was put on tablet rivaroxaban 15 mg for 3 weeks twice a day followed by 20 mg twice a day for 3 months. There were no adverse effects or complications following the procedure, and he did not need any modification of intervention. His symptoms came down postoperatively and had a full recovery within 5 days.


  Discussion Top


Fever, dry cough, and shortness of breath are among the most prevalent symptoms described by COVID-19 patients. Our patients were suffering from mild to moderate case of COVID-19 with classic DVT signs such as edema, redness, and soreness. Mild thrombocytopenia and elevated D-dimer levels are the most stable hemostatic abnormalities associated with COVID-19.[7],[8],[9],[10] Systemic anticoagulation is the most common treatment for DVT. Anticoagulation alone does not improve the prognosis of patients with iliocaval thrombosis, hence adjuvant therapy is frequently used. Surgical thrombectomy has unsatisfactory results[5], and although systemic thrombolysis can dissolve clots in up to 65% of patients, the risk of serious bleeding problems has kept it from becoming widely used. In our cases, there was endovascular filter placement which had successful outcome.[11] Clot clearance and the ability to treat underlying stenosis are both possible with these procedures, which can lower re-thrombosis rates by up to 60%. The IVC filter placement was combined with mechanical thrombectomy in these cases. This residual thrombus was removed quickly and successfully using adjunctive mechanical thrombectomy, highlighting the value of combining diverse methods in difficult venous occlusions.[12]

DVT is thought to be a secondary lesion after COVID-19 at first. The angiotensin-converting enzyme 2, which is distributed throughout blood arteries and many organs, may be the route by which coronavirus affects the human body. The infection then triggers cytokine cascades, which can exacerbate clotting issues and damage. Finally, anything that hinders blood from circulating or clotting normally can produce DVT blood clots, such as injury to a vein, surgery, certain drugs, and limited movement, although the specific origin of COVID-19-induced DVT is yet unknown.[13],[14],[15]


  Conclusion Top


In addition to thrombocytopenia, the actual mechanism of COVID-19-induced DVT formation is unknown and has been recently researched. Although COVID-19 with DVT is a rare symptom, we should recognize DVT from other symptoms as an important symptom for COVID-19 diagnosis in middle-aged patients with sudden onset of symptoms. Control and prevention of DVT in high-risk patients will need rapid diagnostic assays for earlier diagnosis of the disease, effective treatment, and careful utilization of CT scans.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Iba T, Levy JH, Levi M, Thachil J. Coagulopathy in COVID-19. J Thromb Haemost 2020;18:2103-9.  Back to cited text no. 1
    
2.
Davoodi L, Jafarpour H, Taghavi M, Razavi A. COVID-19 presented with deep vein thrombosis: An unusual presenting. J Investig Med High Impact Case Rep 2020;8: 2324709620931239.  Back to cited text no. 2
    
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Al-Otaibi M, Iftikhar O, Brailovsky Y, Rali P, Islam S, Narewski E, et al. Catheter-directed thrombolysis of iliocaval thrombosis in patients with COVID-19 infection. JACC Case Rep 2020;2:2016-20.  Back to cited text no. 3
    
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Shi W, Lv J, Lin L. Coagulopathy in COVID-19: Focus on vascular thrombotic events. J Mol Cell Cardiol 2020;146:32-40.  Back to cited text no. 4
    
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Llitjos JF, Leclerc M, Chochois C, Monsallier JM, Ramakers M, Auvray M, et al. High incidence of venous thromboembolic events in anticoagulated severe COVID-19 patients. J Thromb Haemost 2020;18:1743-6.  Back to cited text no. 5
    
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Klok FA, Kruip MJ, van der Meer NJ, Arbous MS, Gommers DA, Kant KM, et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res 2020;191:145-7.  Back to cited text no. 6
    
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Wool GD, Miller JL. The impact of COVID-19 disease on platelets and coagulation. Pathobiology 2021;88:15-27.  Back to cited text no. 7
    
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Langer F, Kluge S, Klamroth R, Oldenburg J. Coagulopathy in COVID-19 and its implication for safe and efficacious thromboprophylaxis. Hamostaseologie 2020;40:264-9.  Back to cited text no. 8
    
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Zhang L, Yan X, Fan Q, Liu H, Liu X, Liu Z, et al. D-dimer levels on admission to predict in-hospital mortality in patients with covid-19. J Thromb Haemost 2020;18:1324-9.  Back to cited text no. 9
    
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Hayıroğlu Mİ, Çınar T, Tekkeşin Aİ. Fibrinogen and D-dimer variances and anticoagulation recommendations in Covid-19: Current literature review. Rev Assoc Med Bras (1992) 2020;66:842-8.  Back to cited text no. 10
    
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Fu J, Kong J, Wang W, Wu M, Yao L, Wang Z, et al. The clinical implication of dynamic neutrophil to lymphocyte ratio and D-dimer in COVID-19: A retrospective study in Suzhou China. Thromb Res 2020;192:3-8.  Back to cited text no. 11
    
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Singh AK, Gillies CL, Singh R, Singh A, Chudasama Y, Coles B, et al. Prevalence of co-morbidities and their association with mortality in patients with COVID-19: A systematic review and meta-analysis. Diabetes Obes Metab 2020;22:1915-24.  Back to cited text no. 12
    
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Ejaz H, Alsrhani A, Zafar A, Javed H, Junaid K, Abdalla AE, et al. COVID-19 and comorbidities: Deleterious impact on infected patients. J Infect Public Health 2020;13:1833-9.  Back to cited text no. 13
    
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Li Y, Zhao K, Wei H, Chen W, Wang W, Jia L, et al. Dynamic relationship between D-dimer and COVID-19 severity. Br J Haematol 2020;190:e24-7.  Back to cited text no. 14
    
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Barge TF, Wilton E, Wigham A. Endovascular treatment of an extensive iliocaval and renal vein thrombosis secondary to inferior vena cava stenosis and may-thurner type iliac vein compression: A case report. Vasc Endovascular Surg 2020;54:297-300.  Back to cited text no. 15
    



 
 
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