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      Mechanical thrombectomy of COVID-19 DVT with congenital heart disease leading to phlegmasia cerulea dolens: a case report

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          Abstract

          Background

          COVID-19 and Fontan physiology have each been associated with an elevated risk of venous thromboembolism (VTE), however little is known about the risks and potential consequences of having both.

          Case presentation

          A 51 year old male with tricuspid atresia status post Fontan and extracardiac Glenn shunt, atrial flutter, and sinus sick syndrome presented with phlegmasia cerulea dolens (PCD) of the left lower extremity in spite of supratherapeutic INR in the context of symptomatic COVID-10 pneumonia. He was treated with single session, catheter directed mechanical thrombectomy that was well-tolerated.

          Conclusions

          This report of acute PCD despite therapeutic anticoagulation with a Vitamin K antagonist, managed with emergent mechanical thrombectomy, calls to attention the importance of altered flow dynamics in COVID positive patients with Fontan circulation that may compound these independent risk factors for developing deep venous thrombosis with the potential for even higher morbidity.

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          COVID-19 and its implications for thrombosis and anticoagulation

          Jean M Connors, Jerrold Levy (2020)
          Severe acute respiratory syndrome coronavirus 2, coronavirus disease 2019 (COVID-19)-induced infection can be associated with a coagulopathy, findings consistent with infection-induced inflammatory changes as observed in patients with disseminated intravascular coagulopathy (DIC). The lack of prior immunity to COVID-19 has resulted in large numbers of infected patients across the globe and uncertainty regarding management of the complications that arise in the course of this viral illness. The lungs are the target organ for COVID-19; patients develop acute lung injury that can progress to respiratory failure, although multiorgan failure can also occur. The initial coagulopathy of COVID-19 presents with prominent elevation of D-dimer and fibrin/fibrinogen-degradation products, whereas abnormalities in prothrombin time, partial thromboplastin time, and platelet counts are relatively uncommon in initial presentations. Coagulation test screening, including the measurement of D-dimer and fibrinogen levels, is suggested. COVID-19–associated coagulopathy should be managed as it would be for any critically ill patient, following the established practice of using thromboembolic prophylaxis for critically ill hospitalized patients, and standard supportive care measures for those with sepsis-induced coagulopathy or DIC. Although D-dimer, sepsis physiology, and consumptive coagulopathy are indicators of mortality, current data do not suggest the use of full-intensity anticoagulation doses unless otherwise clinically indicated. Even though there is an associated coagulopathy with COVID-19, bleeding manifestations, even in those with DIC, have not been reported. If bleeding does occur, standard guidelines for the management of DIC and bleeding should be followed.
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            Incidence of venous thromboembolism in hospitalized patients with COVID‐19

            Saskia Middeldorp, Michiel Coppens, Thijs F. van Haaps … (2020)
            Abstract Background Coronavirus disease 2019 (COVID‐19) can lead to systemic coagulation activation and thrombotic complications. Objectives To investigate the incidence of objectively confirmed venous thromboembolism (VTE) in hospitalized patients with COVID‐19. Methods Single‐center cohort study of 198 hospitalized patients with COVID‐19. Results Seventy‐five patients (38%) were admitted to the intensive care unit (ICU). At time of data collection, 16 (8%) were still hospitalized and 19% had died. During a median follow‐up of 7 days (IQR, 3‐13), 39 patients (20%) were diagnosed with VTE of whom 25 (13%) had symptomatic VTE, despite routine thrombosis prophylaxis. The cumulative incidences of VTE at 7, 14 and 21 days were 16% (95% CI, 10‐22), 33% (95% CI, 23‐43) and 42% (95% CI 30‐54) respectively. For symptomatic VTE, these were 10% (95% CI, 5.8‐16), 21% (95% CI, 14‐30) and 25% (95% CI 16‐36). VTE appeared to be associated with death (adjusted HR, 2.4; 95% CI, 1.02‐5.5). The cumulative incidence of VTE was higher in the ICU (26% (95% CI, 17‐37), 47% (95% CI, 34‐58), and 59% (95% CI, 42‐72) at 7, 14 and 21 days) than on the wards (any VTE and symptomatic VTE 5.8% (95% CI, 1.4‐15), 9.2% (95% CI, 2.6‐21), and 9.2% (2.6‐21) at 7, 14, and 21 days). Conclusions The observed risk for VTE in COVID‐19 is high, particularly in ICU patients, which should lead to a high level of clinical suspicion and low threshold for diagnostic imaging for DVT or PE. Future research should focus on optimal diagnostic and prophylactic strategies to prevent VTE and potentially improve survival.
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              Effect of Convalescent Plasma Therapy on Time to Clinical Improvement in Patients With Severe and Life-threatening COVID-19: A Randomized Clinical Trial

              Ling Li, Wei Zhang, Yu Hu … (2020)
              Convalescent plasma is a potential therapeutic option for patients with coronavirus disease 2019 (COVID-19), but further data from randomized clinical trials are needed.
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                Author and article information

                Contributors
                Neema Jamshidi:
                ORCID: http://orcid.org/0000-0003-3857-9735
                njamshidi@mednet.ucla.edu
                Jeannette Lin: jeannettelin@mednet.ucla.edu
                Journal
                Journal ID (nlm-ta): BMC Cardiovasc Disord
                Journal ID (iso-abbrev): BMC Cardiovasc Disord
                Title: BMC Cardiovascular Disorders
                Publisher: BioMed Central (London )
                ISSN (Electronic): 1471-2261
                Publication date (Electronic): 9 December 2021
                Publication date PMC-release: 9 December 2021
                Publication date Collection: 2021
                Volume: 21
                Electronic Location Identifier: 592
                Affiliations
                [1 ]GRID grid.19006.3e, ISNI 0000 0000 9632 6718, Department of Radiological Sciences, , UCLA, ; 757 Westwood Ave, Ste 2125, Los Angeles, CA 90095 USA
                [2 ]GRID grid.19006.3e, ISNI 0000 0000 9632 6718, Department of Internal Medicine/Division of Cardiology, , UCLA, ; 757 Westwood Ave, Ste 2125, Los Angeles, CA 90095 USA
                Author information
                http://orcid.org/0000-0003-3857-9735
                Article
                Publisher ID: 2403
                DOI: 10.1186/s12872-021-02403-w
                PMC ID: 8655716
                SO-VID: 04e4e992-75a8-4fbc-8735-8403ec79ae43
                Copyright © © The Author(s) 2021
                License:

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

                History
                Date received : 23 January 2021
                Date accepted : 24 November 2021
                Categories
                Subject: Case Report
                Custom metadata
                issue-copyright-statement © The Author(s) 2021

                ScienceOpen disciplines: Cardiovascular Medicine
                Keywords: femoral and iliac vein thrombosis,venous thromboembolism,mechanical thrombectomy,clottriever,fontan,case report
                Data availability:
                ScienceOpen disciplines: Cardiovascular Medicine
                Keywords: femoral and iliac vein thrombosis, venous thromboembolism, mechanical thrombectomy, clottriever, fontan, case report

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