Heparin Drip Research Articles

DVT, PULMONARY EMBOLISM, AND PARADOXICAL EMBOLISM THANKS TO A CARDIAC CONNECTION

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Concomitant venous and arterial thrombi are usually seen in hypercoagulable states, but we present an unusual case where a patient developed paradoxical embolism of deep venous thrombosis (DVT) and pulmonary embolism (PE) leading to acute limb ischemia due to the presence of a patent foramen ovale (PFO). CASE PRESENTATION: 70-year-old female with history of OSA, hypertension, diabetes on insulin presented to the hospital with sudden onset right lower extremity pain, numbness and weakness of few hours. Patient also complained of dyspnea on exertion that started about 3 weeks prior. At presentation, patient was hypoxic, and examination demonstrated a right lower extremity that was cold to touch and numb with faint dorsalis pedis and posterior tibialis pulses on the right compared to the left. CT chest, abdomen, pelvis with contrast showed an acute extensive pulmonary emboli with right heart strain, acute thrombus at the origin of the celiac trunk, superior and inferior mesenteric arteries, left lower pole renal artery, right common femoral artery, and left internal iliac artery with occlusion of the right common femoral, left internal iliac, and left lower pole renal arteries. Lower extremity venous doppler showed an acute deep venous thrombosis of the left popliteal vein and the femoral vein in the lower thigh. 2D echo with bubble study revealed D-shaped left ventricle due to septal flattening, consistent with elevated right ventricular pressure atrial septal aneurysm and a patent foramen ovale. Patient was started on heparin drip and emergently taken to the operating room for right lower extremity thrombo-embolectomy of right iliac, right femoral, right profunda, right superficial femoral artery, right popliteal artery and 4 compartment fasciotomies. Post-operatively, anticoagulation was changed to Rivaroxaban and was discharged to acute inpatient rehab in stable condition. DISCUSSION: The prevalence of PFO in the general population is more than 25% but most are asymptomatic, the prevalence of DVT was found to be as high as 41% in one study of patients with suspected paradoxical embolism and concomitant patent foramen ovale. Most of the data about PFO closure are for prevention of recurrent cryptogenic stroke with paucity of data on how to manage PFO and paradoxical embolism causing limb ischemia with associated DVT and PE. CONCLUSIONS: A high index of suspicion for PFO should be maintained when a patient with PE and/or DVT presents with concomitant evidence of arterial thromboembolism. Reference #1: 1.Stollberger C, Slany J, Schuster I, Leitner H, Winkler W, Karnik R. The Prevalence of Deep Venous Thrombosis in Patients with Suspected Paradoxical Embolism. Ann Intern Med. 1993;119:461–465. doi: 10.7326/0003-4819-119-6-199309150-00003 Reference #2: 2.Homma, S. and R. L. Sacco (2005). "Patent foramen ovale and stroke.” Circulation 112(7): 1063-1072. DISCLOSURES: No relevant relationships by Nellowe Candelario, source=Web Response No relevant relationships by Adegbola Oluwole, source=Web Response

AN ACUTE MYOCARDIAL INFARCTION CAUSING A MOTOR VEHICLE ACCIDENT OR THE MOTOR VEHICLE ACCIDENT CAUSING AN ACUTE MYOCARDIAL INFARCTION: A CLINICAL DILEMMA

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Acute myocardial infarction is seen in very few patients (0.5%) who are admitted post-motor vehicle accidents (MVAs) (1). It is, however, one of the common natural causes of incapacitation leading to MVA (2). We present a case of a male, who suffered a V-fib cardiac arrest post-MVA and was subsequently diagnosed with a 99 percent occlusion of the proximal left main coronary artery. CASE PRESENTATION: A 68-year old male known to have hypertension was brought to the ED after a head-on motor vehicle collision. EMS reported that the patient self-extricated from the vehicle, walked on the sidewalk, and fell unconscious afterward with V-fib arrest. The patient achieved ROSC after one round of CPR with cardioversion, and 1mg epinephrine. Due to low GCS, he was intubated and transferred to ICU. His labs were significant for elevated white blood cells and troponin of 0.14 (normal<0.03). EKG showed sinus rhythm with non-specific ST-T wave changes in Leads I, aVL, V5, and V6. CT chest showed non-displaced multiple ribs and sternal fractures with small retrosternal hematoma. TTE demonstrated a 25-30% ejection fraction and multiple wall motion abnormalities with apical ballooning. The patient was extubated after his respiratory status showed signs of improvement. Meanwhile, since the troponin levels continued to rise (0.14 < 1.93 < 3.62 < 6.89 < 7.02), heparin drip was started. Although the patient was finally alert and oriented, he had amnesia of the event. However, he denied having any chest pain, or anginal symptoms before the accident. Our differential diagnoses were cardiac injury from either accident or CPR, Takostubo cardiomyopathy, or myocardial infarction. His repeat EKG was different from the one on arrival and showed biphasic T-wave in V2 -V3 and symmetric T-wave inversion in V4-V6. On the second day of his hospital stay, cardiac catheterization was performed that showed 99% proximal LAD stenosis, leading to percutaneous coronary intervention. His status slowly improved and was discharged on a life vest with a follow up with a cardiologist. DISCUSSION: While myocardial injury post blunt trauma, associated with MVAs, are common, thrombotic occlusions are rare. Unlike our case, in a few of the reported cases of thrombotic occlusion, (3) (4) the patients were fairly young. The presentations of the case poised a clinical dilemma because we could not establish if MI caused the MVA or vice-versa. Also, coronary thrombosis was not the top differential diagnosis in this case given the trauma, CPR, rib fractures, and TTE findings. Regardless, a timely cardiac catheterization with revascularization was performed, and the patient recovered. CONCLUSIONS: Acute myocardial infarction should always be one of the differential diagnoses after cardiac injury associated with trauma as timely cardiac catheterization and revascularization can be life-saving. Reference #1: 1.Alkhouli M, Alqahtani F. Incidence and outcomes of acute myocardial infarction during motor vehicle accident related hospitalizations. The American journal of cardiology. 2019 Mar 1;123(5):725-8. Reference #2: 2. Antecol DH, Roberts WC. Sudden death behind the wheel from natural disease in drivers of four-wheeled motorized vehicles. The American journal of cardiology. 1990 Dec 1;66(19):1329-35. Reference #3: 3.Watt AH, Stephens MR. Myocardial infarction after blunt chest trauma incurred during rugby football that later required cardiac transplantation. Heart. 1986 Apr 1;55(4):408-10. 4.Calvo Orbe L, Garcia Gallego F, Sobrino N, Sotillo J, Lopez-Sendon JL, Oliver J, Coma I, Frutos A, Sobrino JA, Navarro JM. Acute myocardial infarction after blunt chest trauma in young people: need for prompt intervention. Catheterization and cardiovascular diagnosis. 1991 Nov;24(3):182-5. DISCLOSURES: No relevant relationships by Abhishek Kalidas Kulkarni, source=Web Response No relevant relationships by Odalys Lara-Garcia, source=Web Response No relevant relationships by Ruby Maini, source=Web Response No relevant relationships by Priyanka Parajuli, source=Web Response No relevant relationships by Manjari Regmi, source=Web Response No relevant relationships by Mohsin Salih, source=Web Response No relevant relationships by Nitin Tandan, source=Web Response

S3566 Spontaneous Celiac Artery Aneurysm in a Healthy Young Male

INTRODUCTION: Celiac artery aneurysms (CAA) are an uncommon form of splanchnic aneurysms, accounting for about 5.1% of cases, and typically effect older males with atherosclerotic disease. Aneurysmal rupture carries a mortality rate of 25–70% with a risk of rupture of 5% with aneurysms 15 mm–22 mm in diameter and a risk of rupture of 50–70% when an aneurysm is greater than 30 mm. Etiology of CAA include atherosclerosis, infectious, trauma, segmental arterial mediolysis (SAM), etc. Below we present an unusual case of a spontaneous CAA in healthy young male with a negative rheumatologic workup and no history of atherosclerosis. CASE DESCRIPTION/METHODS: A 39-year-old male without significant past medical history presented to the ED with five days of bilateral upper quadrant abdominal pain. Initial labs were unremarkable. A computerized tomography (CT) scan of the abdomen and pelvis with contrast was ordered, which showed a 1.1 cm fusiform CAA with a short segment dissection flap, and abnormal wall thickening of the celiac, splenic and proximal common hepatic arteries suggestive of vasculitis (Image 1). Labs showed mildly elevated C-reactive protein of 15.2 mg/L, erythrocyte sedimentation rate of 44 mm/hr, and total complement level >60 U/mL. With the presumptive diagnosis of vasculitis, the patient was started on bowel rest, intravenous methylprednisone and a heparin drip with resolution of his symptoms. The follow-up rheumatological workup for antibodies including antineutrophil cytoplasmic, proteinase 3, myeloperoxidase, anti-nuclear, mitochondrial, and smooth muscle were negative. The patient was started on aspirin 81 mg daily, clopidogrel 75 mg daily and a prednisone taper on discharge. The aneurysm was stable on repeat imaging one month later. DISCUSSION: This is an unusual case of a spontaneous CAA with dissection in an otherwise healthy young male. He was successfully treated with antiplatelet agents and steroids for an underlying vasculitis. CAAs can rupture into the peritoneal cavity thus urgent CT imaging with contrast enhancement in the arterial phase is essential if suspected. Furthermore, CAA can cause extrinsic compression of splenic vessels and hepatic or portal obstruction which can lead to end-organ infarction. Elective endovascular or surgical repair should be considered in low-risk patients with greater than 2 cm or rapidly expanding aneurysms. It is important to keep visceral artery aneurysm on the differential with patients presenting with abdominal pain as the consequences can be grave.Image 1.: CT scan of the abdomen and pelvis with contrast showed a 1.1 cm fusiform CAA with a short segment dissection flap, and abnormal wall thickening of the celiac, splenic and proximal common hepatic arteries suggestive of vasculitis.

S1420 A Rare Case of Superior Mesenteric Vein Thrombosis as a Complication of Pancreatic Pseudocyst Fistulization

INTRODUCTION: Superior Mesenteric (SMV) Thrombus is a rare complication of acute pancreatitis, and multiple factors contribute to its formation, including underlying inflammatory along with venous compression leading to venous stasis. Here, we present a unique case of an SMV thrombus as a result of a pancreatic pseudocyst to SMV fistula in the setting of chronic pancreatitis. CASE DESCRIPTION/METHODS: Patient is a 61-year-old male with a past medical history significant for chronic pancreatitis secondary to chronic alcohol abuse who presented with multiple episodes of nausea and non-bloody, non-bilious vomiting. Labs were notable for a lipase of 161 U/L and an alcohol level >300 mg/dL. Interestingly, the patient denied any abdominal pain, and the physical exam was unremarkable, with a soft, non-tender, non-distended abdomen noted with active bowel sounds. Computed Tomography (CT) Abdomen showed chronic calcific pancreatitis with a 2.5 cm hypodense pancreatic head mass with a proximal SMV thrombosis. Magnetic Resonance Imaging (MRI) Abdomen noted the mass to be a pseudocyst rather than a primary pancreatic malignancy with visualization of a wide connection between the cyst and the adjacent SMV with resultant thrombosis of the SMV, compatible with fistulization. Furthermore, imaging did not reveal acute pancreatitis, attributing visualized fat stranding to the thrombus. Surgery recommended initiation of anti-coagulation, therefore the patient was started on a heparin drip and discharged on apixaban with close surgical follow-up. DISCUSSION: Splanchnic vein thromboses are seen in less than 2% of patients with acute pancreatitis, the majority of these involving the splenic vein, and rarely, the SMV. The pathogenesis for these thrombi is thought to be from the combination of direct damage to the venous wall by freed pancreatic enzymes and compression of the vein by the inflamed pancreas. SMV thrombosis is often diagnosed incidentally on imaging, however, it has a high mortality rate of up to 20–50% due to the risk of small bowel ischemia, therefore anti-coagulation should be considered in these cases. Uniquely in our case, the pathogenesis of the SMV thrombus included a fistula between the pancreatic pseudocyst and the SMV, which has been scarcely reported, in the setting of chronic pancreatitis rather than an acute flare. Our case also warrants the question regarding the utility of longitudinal follow-up with serial imaging in those with chronic pancreatitis to prevent fatal outcomes, including bowel ischemia.Figure 1.: CT Abdomen W Contrast 3 cm round mass is seen in the pancreatic head [red arrow], with peripheral calcifications indicating chronic pancreatitis [green arrow]. The Superior Mesenteric Vein (SMV) is in close proximity with the pancreatic mass [yellow arrow].Figure 2.: MRI Abdomen W WO Contrast (T2WI AXIAL) Revisualization of the mass in the pancreatic head with dependent debris [red arrow]. There is also fistulization from the pseudocyst into the superior mesenteric vein (SMV) [green arrow].Figure 3.: MRI Abdomen W WO Contrast (T2WI CORONAL) Mass in the pancreatic head is T2 hyperintense without wall nodularities, clearly constituting a cyst [red arrow]. There is fistulization into the Superior Mesenteric Vein (SMV) [green arrow] followed by thrombosis [blue arrow].

LARGE SADDLE PULMONARY EMBOLUS IN AN ASYMPTOMATIC PATIENT

SESSION TITLE: Medical Student/Resident Pulmonary Vascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pulmonary embolism (PE) represents a mechanical obstruction of one or more branches of the pulmonary vasculature, usually due to a blood clot. Saddle PE lodges at the bifurcation of the main pulmonary artery, often extending into the right and left main pulmonary arteries. Approximately 3 to 6 percent of patients with PE present with a saddle embolus. We report an atypical case of asymptomatic large saddle PE with normal right heart function. CASE PRESENTATION: A 47-year-old male with history of diabetes, OSA, hypertension, obesity and family history of Factor V Leiden mutation presented with 1-day history of progressively worsening left leg pain and swelling. He denied any fevers, chills, SOB, cough or palpitations, recent surgery, or long car rides. On physical examination, the patient was comfortable, alert and oriented, afebrile, respiratory rate 21/minute, saturating 97% on room air. Laboratory workup was insignificant. EKG showed sinus tachycardia. Venous scan of left lower extremity revealed subacute deep venous thrombosis (DVT) involving the left femoral and popliteal veins. CT pulmonary angiography (CTPA) revealed extensive bilateral pulmonary emboli with large saddle. 2D ECHO revealed normal left ventricle (LV) systolic function with ejection fraction >55% and normal right ventricle (RV) size and function. Patient was started on heparin drip and switched to Eliquis. He was discharged home in a stable condition. DISCUSSION: Saddle PE is a radiologic definition and refers to thrombus that straddles the bifurcation of the pulmonary artery trunk. Saddle PE is found in 2.6% to 5.4% of patients with PE.1,2 Patients with saddle PE presented more frequently with concurrent DVT on hospital admission (75%).3 The presenting symptoms are dyspnea (72%), syncope (43%). Our patient presented with progressive left leg swelling and pain with DVT and no respiratory symptoms. Alkinj et al in 20172 had reported that 18% of patients with saddle PE had normal RV systolic function. One third patients had hemodynamic instability fulfilling the definition of massive PE unlike in our patient. Our patient was hemodynamically stable and had normal RV function, the risk of bleeding outweighed the benefits of fibrinolytic therapy, therefore this patient was managed with conventional treatment. CONCLUSIONS: Despite looking sinister in appearance on imaging studies, patients with saddle pulmonary embolus may be nearly asymptomatic, hemodynamically stable and can be successfully managed with conventional treatment. Reference #1: Ryu JH, Pellikka PA, Froehling DA, Peters SG, Aughenbaugh GL.Saddle pulmonary embolism diagnosed by CT angiography: frequency,clinical features and outcome. Respir Med. 2007;101(7):1537-1542. Reference #2: Alkinj B, Pannu BS, Apala DR, Kotecha A, Kashyap R, Iyer VN. Saddle vs Nonsaddle Pulmonary Embolism: Clinical Presentation, Hemodynamics, Management, and Outcomes. Mayo Clin Proc. 2017;92(10):1511-1518. Reference #3: Girard P, Musset D, Parent F, Maitre S, Phlippoteau C, Simonneau G. High prevalence of detectable deep venous thrombosis in patients with acute pulmonary embolism. Chest 1999;116:903-8. DISCLOSURES: No relevant relationships by Salil Avasthi, source=Web Response No relevant relationships by DEEPTI AVASTHI, source=Web Response No relevant relationships by Rathnavali Katragadda, source=Web Response No relevant relationships by Shanti Pittampalli, source=Web Response

S2216 Mesenteric Ischemia: An Unusual Presentation of COVID-19

INTRODUCTION: We report an unusual case of a patient with COVID-19 who presented with acute mesenteric ischemia without pulmonary symptoms. We believe that this observation has important implications for early identification and management of patients with COVID-19. CASE DESCRIPTION/METHODS: An 87 year-old female with atrial fibrillation, not on anticoagulation due to falls, presented to the ED with acute abdominal pain and bloody diarrhea. She denied recent travel but had exposure to a relative who had COVID-19. Initial vitals, including O2 saturation were normal. On exam she exhibited diffuse abdominal tenderness out of proportion to palpation and bloody stool in the rectum. Laboratory studies:WBC 8.4,RBC 12.7,platelets 277,INR 1.0, PTT 36,CRP 25,D-dimer 2262,LDH 126, and lactate 4.0. CT abdomen and pelvis showed focal occlusion of the SMA with ischemic enteritis and colitis involving the terminal ileum and ascending colon. Moreover, a pneumonia was noted with typical findings of COVID-19. The patient was started on a heparin drip and underwent thrombectomy with catheter-directed thrombolysis. A repeat angiogram demonstrated satisfactory SMA perfusion. The patient’s abdominal pain and bloody diarrhea resolved. A nasopharyngeal swab was taken (SARS-CoV-2 RT-PCR) which resulted positive on day 2 of admission. Though she remained asymptomatic, she was treated with Plaquenil and discharged on day 7 with Xarelto, Plavix, and Atorvastatin.The patient returned 13 days later with dyspnea requiring O2 via NC and no GI symptoms. CXR showed worsening pneumonia. She was treated with antibiotics and steroids and was discharged on day 2 with 2L of O2. DISCUSSION: The mechanism of COVID-19 induced GI injury or thrombosis is unknown. The virus may have certain tropism to the GI tract as evidenced by the presence of virus in the stool. This may be due to the expression of ACE2 receptors in enterocytes to which the virus binds to and enters the cells, thus increasing GI permeability. The small bowel, a lymphoid organ, may serve as an entry for the virus and potentiate the immune response. Endothelial cells also express the ACE2 receptor. Thus, the virus may predispose patients to thrombosis via endothelial dysfunction and activation of the coagulation cascade related to the interaction of the virus with the receptor.No cases of mesenteric ischemia related to COVID-19 were found. Unusual GI presentations of COVID-19 without pulmonary symptoms should alert gastroenterologists to identify those with the illness promptly.Figure 1.: CT abdomen and pelvis with IV contrast with focal occlusion of the SMA with corresponding ischemic enteritis and colitis involving the terminal ileum and ascending colon due to thrombosis.Figure 2.: Angiogram Pre-Catheter Directed Thrombolysis.Figure 3.: Angiogram Post-Catheter Directed Thrombolysis.

S2290 Venous and Arterial Thromboembolism: Unusual Harbinger of Ulcerative Colitis in a 64-Year-Old

INTRODUCTION: Arterial and venous thromboembolic events are known extraintestinal manifestations of inflammatory bowel disease (IBD). Since elderly patients with IBD require tailored treatment strategies, establishing the initial diagnosis and assessing the etiology of future symptoms are critical. We present a 64-year-old male who underwent left iliofemoral vein and artery thrombectomy for phlegmasia with subsequent diagnosis of severe active ulcerative colitis. CASE DESCRIPTION/METHODS: A 64-year-old otherwise healthy white male presented with a 3-month history of abdominal pain, hematochezia, 20 lb unintentional weight loss, and left lower extremity pain. He quit smoking one year prior to presentation and denied family history of IBD or colon cancer. Vital signs were stable and physical exam revealed left leg swelling and tenderness, cyanosis of the left great toe, and positive fecal occult blood test. Labs showed mild normocytic anemia and elevated fecal calprotectin. The abdominal CT showed thrombosis of the left femoral vein, right sided subsegmental pulmonary embolus, distal abdominal aorta mural thrombus, and left iliac artery occlusion (Figure 1). Anticoagulation was not initiated given concerns for lower gastrointestinal bleed. An Inferior Vena Cava filter was placed the following day with stenting of the left common and external iliac arteries, and thrombectomy of the left common femoral, superficial femoral, and external iliac veins. A colonoscopy showed severe inflammation from the rectum to the descending colon (Figure 2). Colonic biopsies showed active chronic colitis with cryptitis and crypt abscesses consistent with ulcerative colitis (UC). Patient was started on steroids, discharged on hospital day 5, and readmitted 5 days later for right leg pain. The Doppler ultrasound showed an occlusive acute Deep Vein Thrombosis (DVT) of the right posterior-tibial vein, nonocclusive DVT of the right common femoral, superficial femoral, and popliteal veins, and occlusion of right proximal superficial femoral artery. He was started on heparin drip, switched to apixaban on hospital day 5, and discharged on hospital day 8. DISCUSSION: The risk of venous thromboembolism is quite high in elderly adults with UC. The literature suggests that thrombosis and hypercoagulability are features of IBD involved in the occurrence of thromboembolic events. Therefore, it is imperative to consider IBD as a differential diagnosis in elderly patients presenting with unprovoked thromboembolism and gastrointestinal bleeding.Figure 1.: Mural thrombus of the distal abdominal aorta and high-grade left iliac artery occlusion.Figure 2.: Colitis up to the descending colon.

S3032 Extra-Gastrointestinal Stromal Tumor (EGIST): An Unusual Case of Worsening Exertional Dyspnea

INTRODUCTION: Gastrointestinal stromal tumors (GISTs) are mesenchymal tumors of the gut. GISTs are rare, composing 0.1-3% of all gastrointestinal tumors. Exceedingly rare cases of GISTs have been identified outside of the GI tract and named extra-gastrointestinal stromal tumors (EGISTs). Here, we present a case of a large EGIST with multiple metastasis that initially presented with worsening exertional dyspnea. CASE DESCRIPTION/METHODS: An 83-year-old female with past medical history significant for hypertension and breast cancer status post lumpectomy and radiation therapy presented with worsening shortness of breath on exertion for 6 weeks. She also reported mild left upper quadrant abdominal pain, weakness, and decreased appetite. On physical exam, her abdomen was distended with splenomegaly noted. CTA of the chest shows right-sided pulmonary emboli without right ventricular strain and intra-abdominal ascites with a markedly enlarged spleen. US of lower extremities was positive for right femoral deep vein thrombosis. The patient was placed on heparin drip, which was later changed to Lovenox. Abdominal US shows multiple intrahepatic lesions and epigastric mass. CT of the abdomen and pelvis shows a large mass occupying a majority of the abdominal and pelvic cavities and multiple metastasis noted to liver and adrenal glands. Core biopsy of the abdominal mass showed high grade (Grade 2, x > 5 mitotic figures per 5 mm) GIST with necrosis. Tumor cells were positive for DOG1, CD117, and CD34. EGD revealed antral gastritis with biopsy positive for H. pylori. She was discharged and placed on Imatinib with repeat imaging after several months of Imatinib to evaluate for possible resection of disease. DISCUSSION: EGISTs are rare mesenchymal tumors that have been identified in the retroperitoneum and pelvis. GISTs result from activating mutations of proto-oncogenes c-KIT (CD117) or PDGFR-alpha. These activated proto-oncogenes increase tyrosine kinase receptor activity and result in stem cell proliferation. Roughly one third of GISTs have malignant potential and are prone to metastatic spread. GIST prognosis is multifactorial, depending on tumor size, mitotic potential, and metastatic invasion. Imatinib, a tyrosine kinase inhibitor, is the first-line therapy of metastatic GIST. In addition, surgical resection is the mainstay of therapy, especially in cases where the lesion is > 2 cm. In the 3 to 5 years post-treatment, close surveillance is warranted due to high risk of GIST recurrence.Figure 1.: Abdominal and Pelvic GIST on CT of the abdomen and pelvis.Figure 2.: Abdominal and Pelvic GIST on CT of the abdomen and pelvis.

ANGINA AND ATRIAL FIBRILLATION IN MELOXICAM USE

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Atrial fibrillation is the most common arrhythmia that affects patients worldwide. Risk factors that contribute to the development of atrial fibrillation include advanced age > 65, hypertension, thyroid disorders, and alcoholic heart disease. We present a case of a male patient who developed atrial fibrillation and angina from meloxicam use. CASE PRESENTATION: A 55-year-old male with history of arthritis, morbid obesity and recent diagnosis of obstructive sleep apnea and hypertension, presented to the ED with intermittent episodes of 5/10 non-radiating retrosternal chest pain. 10-point review of systems was significant for shortness of breath and palpitations. Patient has history of small hand joint arthritis and body pain for which he was taking meloxicam for 3 weeks. Family history was significant for coronary artery disease in father and brother. He consumed 6 beers daily but denied other substance use. Vitals showed blood pressure was 157/104 mm Hg and heart rate in 109 bpm, with a SpO2 96% on room air. EKG showed atrial fibrillation with rapid ventricular response without acute ST-T changes. Troponin was <0.03. Patient was initially managed with loading dose aspirin and heparin drip. Rate control was achieved with two doses of metoprolol 5 mg IV push. The patient was subsequently started on metoprolol 25 mg PO BID and converted to sinus rhythm in 24 hours. Laboratory results showed unremarkable complete blood count, electrolytes, TSH, and lipid panel. Transthoracic echocardiogram demonstrated left ventricular ejection fraction of 55-60% with no signs of left atrial dilation. Nuclear stress test showed likely physiologic fixed apical thinning without any signs of ischemia. Thus, coronary causes of chest pain were ruled out. Patient was subsequently discharged home with metoprolol 25 mg PO BID for rate control and full dose aspirin for CHADS2-VASc of 1. DISCUSSION: Significant risk factors for atrial fibrillation include age > 65, prolonged history of hypertension, and ischemic heart disease. Additional risk factors for atrial fibrillation such as thyroid disorders, pulmonary hypertension, and alcoholic heart disease were ruled out. While APPROVE, APC, and VIGOR trials reported increased cardiovascular risks associated with selective COX-2 inhibitors such as celecoxib, rofecoxib, vedolicoxib, data is limited on adverse cardiovascular effects of meloxicam use (1,2). Our case report elicits the need for heightened awareness of adverse cardiovascular effects of meloxicam. CONCLUSIONS: Given the negative work up and resolution following discontinuation of the agent, the patient’s angina and atrial fibrillation were likely associated with meloxicam use. Further prospective studies should be performed to assess association of non selective COX inhibitors in development of acute cardiac events and long term cardiovascular mortality. Reference #1: Psaty, B. M., & Furberg, C. D. (2005). COX-2 inhibitors--lessons in drug safety. New England journal of medicine, 352(11), 1133-1134. Reference #2: Schmidt, M., Christiansen, C. F., Mehnert, F., Rothman, K. J., & Sørensen, H. T. (2011). Non-steroidal anti-inflammatory drug use and risk of atrial fibrillation or flutter: population based case-control study. Bmj, 343, d3450. DISCLOSURES: No relevant relationships by Mohammad Al-Akchar, source=Web Response No relevant relationships by Abhishek Kalidas Kulkarni, source=Web Response No relevant relationships by Ruby Maini, source=Web Response No relevant relationships by Zurain Niaz, source=Web Response No relevant relationships by Tharani Sundararajan, source=Web Response No relevant relationships by Nitin Tandan, source=Web Response

COVID-19-ASSOCIATED HYPERCOAGUABLE STATE: A CASE OF ACUTE AORTIC THROMBOSIS

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Reports during the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) pandemic have raised concerns for a hypercoagulable state.1 An increased incidence of venous thromboembolism and pulmonary microthrombi have been found on autopsy. We present a case of a spontaneous aortic thrombosis in a patient with SARS-CoV-2. CASE PRESENTATION: A 70-year-old with dyspnea and fevers presented with hypoxia, bilateral pulmonary infiltrates, and tested positive for Coronavirus-19. He was managed with high flow oxygen and was initiated on therapeutic heparin drip for atrial flutter. Laboratory results revealed elevated inflammatory markers (ferritin 932ng/ml, erythrocyte sedimentation rate of 43mm/hour, C-reactive protein of 227mg/L, IL-6 141pg/ml, fibrinogen 606mg/dL, D-Dimer of 1.08ug/mL). The patient was intubated on day three for worsening hypoxia. Bilateral mottled lower extremities were immediately noted, with non-palpable pulses and an arterial doppler confirming absent flow in both femoral arteries. The patient underwent emergent surgical exploration with the discovery of extensive abdominal aortic clot ex-tending into the bilateral femoral and renal arteries on intraoperative aortogram. Despite emergent thrombectomies, the muscle tissue demonstrated extensive non-viability, and bilateral above the knee amputations were performed. The patient’s condition continued to deteriorate, with the development of rhabdomyolysis, severe shock, and acute renal failure. The family made a decision to pursue comfort care secondary to futility. DISCUSSION: Individuals with COVID-19 have a number of coagulation abnormalities. Direct invasion of endothelial cells by the SARS-CoV-2 virus, potentially leading to cell injury, in addition to other indirect mediators of endothelial injury (interleukin [IL]-6), other acute phase reactants and complement-mediated endothelial injury have been postulated to contribute to the hypercoagulable state and clot pathogenesis.2 COVID-19 has been widely accepted to lead to the development of venous and pulmonary micro-emboli. There are however less frequent reports of arterial thrombosis (strokes, acute coronary syndrome, acute limb ischemia).3 This case is the first report of an acute central arterial thrombosis likely secondary to the SARS-CoV-2 virus, in a patient who was already being treated with heparin. This may demonstrate resistance to anticoagulation, the etiology of which needs further investigation. CONCLUSIONS: Life-threatening arterial thromboses are likely within the spectrum of the SARS-CoV-2 virus syn-drome. Serious consideration should be made to anticoagulate these patients to prevent clots with careful monitoring of the coagulation profile to ensure adequate protection. Reference #1: Klok FA et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res.2020;S0049-3848(20)30120-1. Reference #2: Magro C, Mulvey JJ, Berlin D, Nuovo G, Salvatore S, Harp J, Baxter-Stoltzfus A, Lau-rence J. Complement associated microvascular injury and thrombosis in the pathogenesis of severe COVID-19 infection: a report of five cases. Transl Res. 2020 Reference #3: Paolo Perini, Bilal Nabulsi, Massoni CB, Matteo Azzarone, Antonio Fryries. Acute limb ischemia in two young, non-atherosclerotic patinet with COVID-19. The Lancet. 2020 Vol. 395 (10236) P1546. Doi: https://doi/org/10.1016/S0140-6736(20)31051-5. DISCLOSURES: No relevant relationships by Logan Hostetter, source=Web Response No relevant relationships by Bibi Aneesah Jaumally, source=Web Response No relevant relationships by Ruckshanda Majid, source=Web Response No relevant relationships by Joanna Scoon, source=Web Response

S2198 Upper GI Bleed Due to an Uncommon, but Potentially Fatal Bacteria

INTRODUCTION: The most common etiology of peptic ulcer disease is infection with Helicobacter pylori. However, other organisms have also been described in the literature. Sarcina ventriculi is an anaerobic, gram-positive, carbohydrate-fermenting cocci that replicates in low pH environments. It has been associated with gastric ulcers, emphysematous gastritis and gastric perforation. We report a case of a large gastric ulcer in the setting of S. ventriculi infection. CASE DESCRIPTION/METHODS: A 42-year-old male with past medical history of diabetes, end-stage renal disease and hypertension presented to the hospital with S. aureus bacteremia. Endocarditis was ruled out with an echocardiogram. An ultrasound of the right arm found an occlusion of his arterio-venous graft. This was excised, but he developed an occlusion of the right brachial artery requiring a heparin drip and thrombectomy. He was transitioned to dual-antiplatelet therapy but developed melena with a one-gram drop in hemoglobin. Upper endoscopy, showed a large non-bleeding gastric ulcer (Figure 1). Clopidogrel was discontinued. He was placed proton pump inhibitor (PPI), and back on heparin due to risk for limb ischemia. In the interim, he required several transfusions. A non-bleeding gastric ulcer and erosive gastropathy were found on repeat endoscopy. Pathology revealed S. ventriculi, and presence of granules from sevelamer (Figures 2 and 3). He was treated with ciprofloxacin and metronidazole for a week and sevelamer was discontinued. DISCUSSION: Gastroparesis and low pH create an ideal environment for S. ventricularis proliferation. With overgrowth, it is able to penetrate the gastric wall and produce gas, leading to complications such as emphysematous gastritis and perforation. However, patients most commonly present with nausea, dyspepsia, diarrhea or bleeding. When present, S. ventricularis are unlikely to initiate gastric injury, but under ideal circumstances can cause life-threatening disease. Symptomatic patients and those with predisposing risk factors such as: cystic fibrosis, gastric surgery, obstructing malignancy, PEG tubes and diabetic gastropathy should be treated. Metronidazole and ciprofloxacin or gentamicin have been used in combination, as well as imipenem alone. PPIs are used as an adjunct as they increase gastric pH and theoretically help eradicate S. ventriculi.Figure 1.: Upper endoscopy revealing gastropathy and ulcer in lesser curvature.Figure 2.: H&E stain of gastric biopsy showing Sarcina ventriculi. Arrow points towards tetrad formation.Figure 3.: Biopsy of lesser curvature of stomach with fibrinopurulent exudate, reactive changes in mucosa and pill fragments. Arrow points towards Sarcina ventriculi.

PAY ATTENTION! AN UNUSUAL CASE OF DYSPNEA

SESSION TITLE: Medical Student/Resident Cardiothoracic Surgery Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Platypnea-orthodeoxia is an uncommon syndrome characterized by dyspnea and hypoxemia in upright position that improves with recumbent position. It can occur due to intracardiac shunts, pulmonary arteriovenous shunts and ventilation perfusion mismatch. We present a unique and rare cause of platypnea-orthodeoxia syndrome. CASE PRESENTATION: A 68 years old man with history of coronary artery disease and COPD presented with acute onset chest pain and associated difficulty breathing. Patient did have several months’ history of exertional dyspnea which did not improve with rest this time. On presentation, patient was noted to be hypoxic with oxygen saturation of 88% and ABG showed PH 7.41, PaO2 47 mmHg and PaCO2 22.4 mmHg. Oxygen saturation improved to 94% with 3L of supplemental oxygen. EKG and troponin were unremarkable. CT PE was unremarkable for pulmonary embolism as well. IV heparin drip was started for suspected unstable angina and patient underwent cardiac catheterization that revealed non-obstructive coronary artery disease. Echocardiography showed ejection fraction of 55-60% with mild mitral and tricuspid regurgitationDuring the course of hospitalization, patient was noted to have intermittent positional hypoxemia. He had normal resting saturation on 2 L of oxygen which dropped to 88% sitting upright and dropped to 84% on 2 L of oxygen upon raising both arms. Platypnea-orthodeoxia syndrome was strongly suspected with possible intra-cardiac or intrapulmonary shunt. Meanwhile, CT chest was unremarkable for interstitial lung disease. Right heart catheterization revealed normal right atrial RA (68.9%) and pulmonary arterial PA (68.3%) saturation at rest but reduced RA (42.5%) and PA (43.2%) saturation with sitting up. Echocardiography with bubble study showed right-to-left shunting and trans-esophageal echocardiography revealed a small 0.5 cm atrial septal defect (ASD) with bidirectional shunting. Patient was diagnosed with Platypnea-orthodeoxia syndrome secondary to ASD. He was discharged home on supplemental oxygen and outpatient follow-up for ASD closure. DISCUSSION: Platypnea-orthodeoxia is a rare syndrome. Patent foramen ovale is the most common cardiac cause of platypnea-orthodeoxia syndrome followed by ASD. Transesophageal echocardiography is the best test to diagnose atrial septal defect but it is important to rule out pulmonary causes of platypnea-orthodeoxia syndrome as well. ASD is successfully treated with percutaneous closure and prognosis of is good after correction of the defect. CONCLUSIONS: Platypnea-orthodeoxia syndrome is rare syndrome but it can be easily recognized with careful history and physical examination. Reference #1: Henkin S, Negrotto S, Pollak PM, Cullen MW, O'Cochlain DF, Wright RS. Platypnea-Orthodeoxia Syndrome: Diagnostic Challenge and the Importance of Heightened Clinical Suspicion. Tex Heart Inst J. 2015;42(5):498-501. Published 2015 Oct 1. doi:10.14503/THIJ-14-4596 Reference #2: Kazawa S, Enomoto T, Suzuki N, et al. Platypnea-orthodeoxia Syndrome in a Patient with an Atrial Septal Defect: The Diagnosis and Choice of Treatment. Intern Med. 2017;56(2):169-173. doi:10.2169/internalmedicine.56.7728 Reference #3: PLATYPNEA ORTHODEOXIA SYNDROME: A RARE COMPLICATION OF IATROGENIC ATRIAL SEPTAL DEFECT. Bharat Avirneni, Christopher Rosse, Joseph Choo, Kalpan Desai. J Am Coll Cardiol. 2020 Mar, 75 (11 Supplement 1) 2799. DISCLOSURES: No relevant relationships by Muhammad Aamir, source=Web Response No relevant relationships by Muhammad Afzal, source=Web Response No relevant relationships by Saleha Dar, source=Web Response

Outpatient Ultrafiltration to Prevent Hospital Readmission During Covid 19 Pandemic in Diuretic Intolerant Patient: Case Study

IntroductionHeart Failure (HF) is the leading cause of hospitalization among adults greater than 65 years of age in the U.S. and results in over 1,000,000 hospitalizations annually. Despite advances in medical therapeutics, mortality remains high. Adjustments in workflow across hospital systems have been instituted to reduce HF hospitalizations. Ambulatory HF clinics have helped in this regard. In the current COVID-19 pandemic, the need to minimize utilization of hospital resources and limit patient hospital admissions is paramount. Inpatient ultrafiltration (UF) has been utilized to improve congestion in patients with acute decompensated heart failure (ADHF). Less is known of outpatient utilization of UF in the ambulatory HF patient. We present a case of outpatient UF to reduce congestion in an ambulatory HF patient to minimize hospitalization in the era of COVID-19 pandemic.CaseA 70-year-old female with HF preserved ejection fraction, combined pre and post pulmonary capillary hypertension, with chronic dyspnea on continuous home oxygen, who presented to the HF clinic. The patient had previous multiple hospitalizations due to recurrent congestion, with therapies limited by dermatologic biopsy proven allergy to sulfa based diuretics. She had failed various diuretic regimens with recurrent desquamating whole body rash. She had recurrent weight gain during the COVID-19 pandemic, and again was refractory to outpatient therapies. Given her co-morbidities, she was deemed high risk for COVID-19 exposure. A decision to proceed with outpatient UF was made. The day of outpatient HF clinic visit, we placed a brachial dual lumen 16-gauge extended length catheter. A heparin drip was initiated thirty minutes prior to the start of UF per protocol. Baseline serum creatinine was 1.24 mg/dl and estimated GFR was 44. Initial outpatient session was performed over a total of 4-hours with isolated veno-venous UF utilizing the Aquadex Flex Flow system at a rate of 200 cc/hr fluid removal. The patient completed a total of 4 sessions, and total fluid removal was 4950mL. (Table 1) The patient had immediate improvement in symptoms.DiscussionUF is a method of decongestion that can be used as an alternative to loop diuretics. Simplified UF devices can utilize peripheral venous access, low blood flows, and small extracorporeal blood volume. Previous experience with intermittent outpatient UF utilizing peritoneal dialysis and hemofiltration has been reported, though not widely utilized. This is the first case to report the use of the Aquadex Flex Flow system to provide outpatient UF therapies in the COVID-19 era.ConclusionsPre-existing cardiac and pulmonary disease, including congestive HF, increase risk of serious complications from exposure to SARS-COVID-2 virus. We report a novel case of minimizing exposure risk of a congested HF patient using outpatient isolated veno-venous UF in the ambulatory setting.

Early Post-operative Pump Thrombosis In Heartmate 3 LVAD Recipients: A Case Series

Background The HeartMate 3 (HM3) left ventricular assist device (LVAD) has a low reported rate of pump thrombosis. In this case series, we report two HM3 LVAD recipients who developed acute pump thrombosis in the early post-operative period. Case 1 A 69 M with ischemic cardiomyopathy who underwent HM 3 implant as destination therapy (DT). Apical calcium was noted intra-operatively and was removed at the time of surgery. On post-operative day 3, the patient developed low flows alarms, high powers, and increased arterial line pulsatility. Lactate dehydrogenase (LDH) was within normal limits and heparin was therapeutic. Pump interrogation demonstrated rising pump temperature (70°C) with intermittent pump stops. The decision was made to return to the operating room (OR) and during this time the patient developed hypotension and lactic acidosis. In the OR fresh thrombus of the inflow, pump and outflow graft was encountered. The pump was exchanged to a new HM3 and the patient had full recovery with no further thrombotic events. Case 2 A 58-year-old woman with Adriamycin associated cardiomyopathy underwent DT HM3 implantation with tricuspid valve annuloplasty. The LV cavity size decreased from 5.9 cm pre- operatively to 4.0 cm post-operatively, causing septal contact with the inflow cannula and intermittent ventricular tachycardia. On post-operative day 3 the patient developed low flow alarms, followed by elevated pump flows and powers and return of arterial line pulsatility. LVAD interrogation demonstrated a high pump temperature (75 °C) with intermittent pump stops. Similar to the first patient, the second patient had a normal LDH, was therapeutic on a heparin drip, and developed hemodynamic instability. The same findings (inflow, outflow, and intra pump thrombus) were present at in the OR. This second patient's pump was re-positioned reduce septal contact at the time of exchange. Discussion Here we report 2 cases of acute HM3 pump thrombosis shortly after LVAD implantation. Full investigation into these events internally and with the manufacturer did not reveal pump malfunction. The first event was felt to be caused by ingestion of calcified material from the left ventricle leading to rotor misplacement and subsequent thrombus formation. The second case was thought to be triggered by sustained low flow from the septal contact with subsequent thrombus formation. In each case, the patients developed high powers, return arterial line pulsatility, and dangerously high internal pump temperatures. The purpose of this case series is to help the community develop pattern recognition in order to be able to quickly diagnose this rare but serious event.

Extensive Peripheral Arterial Thrombosis in a Patient with SARS-CoV-2 Infection.

Thrombosis is one of the major underlying pathogenetic mechanisms leading to increased morbidity and mortality among COVID-19 patients. Thromboembolic events as well as severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) are the major causes of death in this continued pandemic. While elevated D-dimer level suggests worse thrombotic outcomes, levels at which benefits of anticoagulation outweigh the bleeding risk is yet to be determined. In this report, we present a case of a 72-year-old man with COVID-19 presented with confusion and subsequently developed acute hypoxic respiratory failure. On hospital day 7, patient developed extensive peripheral arterial thrombosis with acute rise of D-dimer from 800 to 14,899 ng/ml. He was treated with heparin drip and underwent urgent brachial, radial and ulnar embolectomy under general anesthesia. In this report, we also discuss the pathogenetic mechanisms and management of thromboembolism in COVID-19 patients, highlighting the role of early detection and aggressive therapeutic interventions that could be life and / or limb saving strategy.

Association of timing of initiation of pharmacologic venous thromboembolism prophylaxis with outcomes in trauma patients.

Patients are at a high risk for developing venous thromboembolism (VTE) following traumatic injury. We examined the relationship between timing of initiation of pharmacologic prophylaxis with VTE complications. Trauma quality collaborative data from 34 American College of Surgeons Committee on Trauma-verified levels I and II trauma centers were analyzed. Patients were excluded if they were on anticoagulant therapy at the time of injury, had hospitalization <48 hours, or received no or nonstandard pharmacologic VTE prophylaxis (heparin drip). Patient comparison groups were based on timing of initiation of VTE prophylaxis relative to hospital presentation (0 to <24 hours, 24 to <48 hours, ≥48 hours). Risk-adjusted rates of VTE events were calculated accounting for patient factors including type of pharmacologic agent in addition to standard trauma patient confounders. A sensitivity analysis was performed excluding patients who received blood in the first 4 hours and/or patients with a significant traumatic brain injury. Within the 79,386 patients analyzed, there were 1,495 (1.9%) who experienced a VTE complication and 1,437 (1.8%) who died. After adjusting for type of prophylaxis and patient factors, the risk of a VTE event was significantly increased in the 24- to <48-hour (odds ratio, 1.26; 95% confidence interval, 1.09-1.47; p = 0.002) and ≥48-hour (odds ratio, 2.35; 95% confidence interval, 2.04-2.70; p < 0.001) cohorts relative to patients initiated at 0 to <24 hours. These VTE event findings remained significant after exclusion of perceived higher-risk patients in a sensitivity analysis. Early initiation of pharmacologic VTE prophylaxis in stable trauma patients is associated with lower rates of VTE. Diagnostic, level III.

Current Outcomes of Blunt Vertebral Artery Injuries

There is no consensus on the treatment of blunt vertebral artery injuries, and studies are limited to small case series. We assessed the natural history and current management of these injuries. We performed a retrospective study of a prospectively collected registry at a level I trauma center over a 5-year period. Additional information was gathered from patient charts and imaging review from electronic medical records. We analyzed demographics, mechanism of injury, Glasgow Coma Score, mortality, length of stay, associated injuries, Denver grading scale, neurological findings, level and laterality of injury, delay in diagnosis, treatment, and follow-up imaging. There were 13,080 trauma admissions during this time period yielding 141 patients with blunt vertebral artery injuries from 2013 to 2018 (1.1% incidence). Mean injury severity score (ISS) was 22 with a 30-day mortality of 14 (9.9%). An ISS of greater than 15 is associated with polytrauma and increased mortality. There were 112 (79.4%) associated cervical fractures. C6 and C7 were both equally the most common locations. There was one symptomatic injury manifesting as a cerebellar ischemic infarct. The degree of arterial injury was classified by the Denver grading scale. There were 61 (43.3%) instances of Denver grade I injuries, followed by grade IV at 36 (25.5%), grade II at 34 (24.1%), grade III at 8 (5.7%), and grade V at 1 (0.7%). The level of injury was recorded as follows: V2=67 (47.5%), V3=56 (39.7%), V1=48 (34%), V4=14 (9.9%). Medical therapy included aspirin in 93 patients (66%), 31 patients (22%) received systemic anticoagulation with heparin drip, and 2 patients (1%) were administered therapeutic Lovenox. A total of 15 patients (11%) received no medical treatment. There was one intervention in our series. Our only grade V injury was coil embolized. A total of 118 patients (84%) had follow-up imaging. Seventy-eight patients (96%) with grade I and grade II injuries did not worsen, and complete radiographic resolution was found in 50 patients (62%). Grade IV injuries persisted in 22 patients (75.9%). Median time to resolution for grade I and grade II injuries was 7 and 8days, respectively. Most follow-up scans for grade I and II injuries occurred within 50days. Posterior circulation stroke due to blunt vertebral artery injury is rare. In our experience, the natural course of blunt vertebral artery injury was benign and neither delay in medical treatment nor choice of antithrombotic had a significant impact on outcomes. In our series, only 3 (3.7%) grade I and II injuries worsened and were without any clinical sequelae. We suggest that routine serial imaging in grade I and II blunt vertebral injuries is not warranted.

Pulmonary Gangrene due to a Septic Emboli in a Young Female

18 year old non-smoker female from California with pmhx of asthma presented with right knee pain and shortness of breath. On admission, vitals were stable, saturating well on room air. MRI of knee confirmed parietal gastrocnemius tear along with some hyperintensity of bone marrow of femur. Chest X-ray on admission revealed bilateral multifocal opacities. Upon admission, influenza and coccidioides serology were negative. Ultrasound doppler of the right lower extremities revealed deep vein thrombosis. Computerized tomography angiogram chest revealed subsegmental pulmonary embolism within the right lower lobe, with bilateral opacities. Heparin drip for management for acute PE and DVT. Due to decreasing oxygen saturation to 93%, the patient required 4 L/ min via nasal cannula.

Acute Abdominal Pain in a COVID-19 Patient

Clinical Images in Nephrology and Dialysis Case Report A 69-year-old woman with a medical history of diabetes, hypertension, coronary artery disease, and acute embolic cerebrovascular event postcardiac catheterization in 2016 presented to the emergency department with acute abdominal pain. Before this, she had been evaluated for symptoms of cough, shortness of breath, and myalgias which were conservatively managed with improvement. She now presented with intermittent pain of diffuse, nonspecific distribution, associated with nausea and nonbloody emesis. The patient also had lower back pain but not in either flank region. She denied history of trauma or urinary symptoms. Her medications included aspirin, clopidogrel, furosemide, and insulin. Examination was significant for diffuse nonspecific abdominal tenderness without rebound or guarding. Laboratory assessment revealed creatinine of 1.10 mg/dl, elevated level of c-reactive protein at 20 mg/dl, sedimentation rate of 112 mm/h, lactic dehydrogenase level of 458 U/L, fibrinogen level of 737 mg/dl, and she tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Urine evaluation had 1.5 g of protein/g creatinine without hematuria. A computed tomography of the abdomen and pelvis with intravenous contrast revealed a nonocclusive thrombus in the left renal artery (Figure 1, A and B) with several large wedge-shaped areas of decreased enhancement, consistent with multiple left renal infarctions (Figure 1C). She was started on an intravenous heparin drip and transitioned to apixaban. During her hospitalization, her abdominal pain improved, renal function remained preserved, and she was then discharged.Figure 1.: Computerized tomography (CT) scan. (A and B) Thrombus in the left renal artery represented by greens arrows. (C) Decreased enhancement consistent with multiple left renal infarctions represented by red arrow.Discussion What began as a series of cases of viral pneumonia initially described in Wuhan, Hubei, China, rapidly spread to emerge as a global pandemic. The virus was identified as SARS-CoV-2 and is the cause of coronavirus disease 2019 (COVID-19). Kidney injury has been associated with this infection, although the exact mechanism of injury remains unclear. Increased severity of illness has been associated with the development of coagulopathy (1). Laboratory abnormalities including leukopenia, lymphopenia, elevated prothrombin time, and d-dimer have been found in patients who are critically ill (2). A case series from Wuhan described patients with COVD-19 testing positive for anti-cardiolipin IgA and anti–β2-glycoprotein I IgA and IgG antibodies (3). Although not specific to this infection, it is hypothesized to be associated with the development of both micro- and macrovascular thrombi. A small study observed a mortality benefit in patients with severe sepsis receiving anticoagulation with low mol wt heparin (low mol wt heparin 40% versus controls 64%) (4). These preliminary data have led international societies to recommend anticoagulation in patients who are critically ill and infected with SARS-CoV-2. Literature has described both microvascular and macrovascular coagulopathy to be associated with severe COVID-19 infection (1); however, abnormal coagulation with the development of clots has not been described in patients with relatively mild disease. Whereas venous thromboembolism and pulmonary embolism have been reported (5), no reports of renal artery thrombosis or renal infarction have been described. Our patient with relatively mild COVID-19 had derangements in coagulation markers and had a renal artery thrombus with renal infarction. Further studies are warranted to evaluate whether renal infarctions are playing a role in the AKI and whether prophylactic anticoagulation could have benefit in renal outcomes. Teaching Points Patients who present with SARS-CoV-2 infection, regardless of severity of disease, should be evaluated for coagulopathy and development of thrombi because these may potentially contribute to infarction and end-organ damage. Renal infarction should be considered part of the differential when evaluating a patient with COVID-19 presenting with abdominal pain or AKI. Initiation of anticoagulation should be considered in those who are critically ill, although it would be imperative to weigh the risks and benefits of this intervention. Disclosures All authors have nothing to disclose. Funding None.

Factors associated with skin graft take in fibula and radial forearm free flap donor sites.

Identify factors associated with skin graft take in fibula free flaps (FFF) and radial forearm free flaps (RFFF) donor sites. To determine which factors are associated with decreased skin graft take at the donor site in FFF and RFFF in head and neck patients. Retrospective Chart Review Case Series. Multicenter Tertiary Care. A multicenter retrospective review was performed at three institutions identifying patients who underwent free tissue transfer, specifically either FFF or RFFF, between 2007 and 2017. Patient demographics, medical history, and social history were examined including age, gender, BMI, smoking status, diabetes and preoperative anticoagulation use. Preoperative, intraoperative data, and postoperative data were also examined including tourniquet use, type of flap, area of skin graft, if the skin graft had a donor site or if it was taken from the flap, wound NPWT use, cast use, use of physical therapy, DVT prophylaxis, limb ischemia, heparin drip, and postoperative aspirin use. Statistical analysis was used to determine which factors were significantly associated with skin graft take. 1415 patients underwent a forearm or fibula flap and 938 patients underwent split-thickness skin graft. Of these, 592 patients had sufficient information and were included in the final analysis. There were 371 males and 220 females. The average age was 55.7. Complete skin graft take was seen in 480 patients (81.1%). On univariate analysis, patients with diabetes (p=.003), type of flap (fibula p<.001), skin graft area (p=.006), tourniquet use (p=.003), DVT prophylaxis (p=.008) and casting (p=.003) were significantly associated with decreased skin graft take rate. In a multivariate analysis, diabetes (OR 2.17 (95%CI 1.16-3.98)), fibula flaps (OR 2.86 (95%CI 1.79-4.76)), an increase in skin graft area (OR 1.01 (95%CI 1.01-1.01)), post-operative aspirin (OR 2.63 (95%CI 1.15-5.88), and casting (OR 2.94 (95%CI 1.22-7.14)) were associated with poor rates of skin graft take. Several factors affect skin graft take rate and should be considered when performing a skin graft for a donor site defect.