J Vasc Surg. 2020 Aug 27:S0741-5214(20)31879-6. doi: 10.1016/j.jvs.2020.07.089. Online ahead of print.
INTRODUCTION: Little is known about the arterial complications and hypercoagulability associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. We sought to characterize our experience with arterial thromboembolic complications in patients with hospitalized for coronavirus disease 2019 (COVID-19).
METHODS: All patients admitted from March 1 to April 20, 2020 and who underwent carotid, upper, lower and aortoiliac arterial duplex, CT angiogram or MRA for suspected arterial thrombosis were included. A retrospective case-control study design was used to identify, characterize and evaluate potential risk factors for arterial thromboembolic disease in SARS-CoV-2 positive patients. Demographics, characteristics and laboratory values were abstracted and analyzed.
RESULTS: During the study period, 424 patients underwent 499 arterial duplex, CT angiogram or MRA imaging studies with overall 9.4% positive for arterial thromboembolism. Of the 40 patients with arterial thromboembolism, 25 (62.5%) were SARS-CoV-2 negative or admitted for unrelated reasons and 15 (37.5%) were SARS-CoV-2 positive. The odds ratio for arterial thrombosis in COVID-19 was 3.37 (95% CI 1.68 - 6.78, p=0.001). Although not statistically significant, in patients with arterial thromboembolism, patients who were SARS-CoV-2 positive compared to those testing negative or not tested tended to be male (66.7 % v. 40.0%, p=0.191), have a less frequent history of former or active smoking (42.9% vs 68.0%, p=0.233) and have a higher white blood cell count (WBC 14.5 vs. 9.9, p=0.208). While the SARS-CoV-2 positive patients trended toward a higher the neutrophil-to-lymphocyte ratio (8.9 vs. 4.1, p=0.134), CPK level (359.0 vs. 144.5, p=0.667), CRP level (24.2 vs. 13.8, p=0.627), LDH level (576.5 vs. 338.0, p=0.313) and ferritin level (974.0 vs. 412.0, p=0.47), these did not reach statistical significance. Patients with arterial thromboembolic complications and SARS-CoV-2 positive when compared to SARS-CoV-2 negative or admitted for unrelated reasons were younger (64 vs. 70 years, p=0.027), had a significantly higher body mass index (BMI) (32.6 vs. 25.5, p=0.012), a higher D-dimer at the time of imaging (17.3 vs. 1.8, p=0.038), a higher average in hospital D-dimer (8.5 vs. 2.0, p=0.038), a greater distribution of patients with clot in the aortoiliac location (5 vs. 1, p=0.040), less prior use of any antiplatelet medication (21.4% vs. 62.5%, p=0.035) and a higher mortality rate (40.0 % vs. 8.0%, p=0.041). Treatment of arterial thromboembolic disease in the COVID-19 positive patients included open thromboembolectomy in 6 patients (40%), anticoagulation alone in 4 (26.7%) and 5 (33.3%) did not require or their overall illness severity precluded additional treatment.
CONCLUSIONS: Patients with SAR-CoV-2 are at risk for acute arterial thromboembolic complications despite a lack of conventional risk factors. A hyperinflammatory state may be responsible for this phenomenon with a preponderance for aortoiliac involvement. These findings provide an early characterization of arterial thromboembolic disease in SARS-CoV-2 patients.