Severe Ischemic Complications Research Articles

Terlipressin-induced skin necrosis in cirrhotic patients-A case report and comprehensive literature review.

The occurrence of terlipressin-induced skin necrosis in cirrhotic patients is a rare but serious adverse event that warrants further investigation. Clinicians should be aware of this potential complication in cirrhotic patients receiving terlipressin therapy and closely monitor for any signs of skin necrosis. Early recognition and prompt intervention are crucial in preventing further complications and improving patient outcomes. Further research is needed to better understand the risk factors associated with terlipressin-induced skin necrosis and to develop effective preventive strategies. Overall, healthcare providers should exercise caution when prescribing terlipressin to cirrhotic patients, weighing the potential benefits against the risks of this rare but significant adverse event. Terlipressin is commonly used to manage conditions related to portal hypertension, such as hepatorenal syndrome and esophageal variceal bleeding. Despite its therapeutic benefits, terlipressin can rarely lead to severe ischemic complications involving the skin vasculature, known as terlipressin-induced skin necrosis. We present a 50-year-old male with cirrhosis and acute variceal bleeding who developed skin necrosis following terlipressin administration. We performed a comprehensive review of the literature by analyzing 18 case reports/case series comprising 22 cirrhotic patients with terlipressin-induced skin necrosis. Among these individuals, we found a mean age of 51 years with a male predominance (78%). Further analysis showed that the onset of skin necrosis ranged from 2 to 5 days post-terlipressin initiation, with bolus administration being predominant (85.7%). The underlying pathophysiological mechanisms of terlipressin-induced skin ischemia are still elusive but primarily attributed to the vasoconstrictive and thrombogenic effects. Management involves terlipressin discontinuation and supportive care. Physicians should be aware of this potential complication in patients receiving terlipressin and closely observe for any signs of skin rash.

ThP8.7 - Giant Cell Arteries: Diagnostics

Abstract Aim Giant cell arteritis (GCA) poses a risk of severe ischaemic complications such as irreversible blindness which mandates early recognition of condition. We aimed to evaluate effectiveness of ultrasound doppler (USD) in diagnosing GCA compared to temporal artery biopsy (TAB) and American College of Rheumatology (ACR) score. Method This retrospective study included patients with suspected GCA who had consecutive TAB and USD examinations performed over a course of three years (2017-2022) which was correlated with ACR score. The data was also analysed to assess further management. Results There were 64 patients over this period who had both studies performed (22 were excluded as they did not have TAB) with 64% having an ACR score ≥3. Twenty males and forty-four females with a median age of 77 years (IQR 84-67). Overall, 81% patients had a negative USD result. Comparing USD results with TAB gold standard, there was sensitivity of 63% and specificity of 84%. Comparing USD results with ACR as gold standard, there was sensitivity of 20% and specificity of 83%. Forty percent patients with negative doppler result were continued on treatment mainly due to improvement of symptoms in response to steroids. Conclusion US Doppler has high diagnostic specificity and low sensitivity which makes it time-efficient, cost-effective and allows for the implementation of fast-track management pathway for majority patients. In certain circumstances, as cases of low clinical suspicion and positive doppler result, an additional test (TAB) would be required to confirm the diagnosis and cases where clinical suspicion is high with negative doppler, TAB should be considered.

Clinical Phenotypes of Giant Cell Arteritis: Insights into Complications and Survival Outcomes.

Giant cell arteritis (GCA) is a heterogeneous disease with diverse clinical presentations and varying degrees of severity. This study aimed to assess the incidence of 3 clinical subsets in GCA and analyze associated severe complications and survival rates. By identifying distinct clinical patterns, the goal is to customize treatment approaches and minimize severe complications during follow-up. This retrospective study classified clinical manifestations of GCA into 3 major phenotypes based on the reason for consultation: i) cranial, ii) extracranial, and iii) occult GCA. These groups were analyzed and compared for acute complications, including severe ischemic complications, "true" occlusive disease, and late complications such as aortic aneurysm. Survival data were also collected during follow-up. Visual disturbances were more common in the cranial GCA group compared to other subsets (P < .001). Blindness and stroke showed a clinically relevant trend, although statistical differences were not significant between the cranial GCA groups. Limb claudication was significantly more prevalent in the extracranial subset compared to the cranial or occult GCA subsets (12% vs. 2.6% vs. 0% respectively). Severe ischemic complications and true occlusive disease were more frequent in the cranial GCA groups (60%, P=.005 and 40%, P=1.64 respectively). Regarding mortality, there were no statistically significant differences in survival among the different clinical subsets. However, the occult GCA subset showed a trend towards a higher prevalence of deaths, both overall and specifically due to GCA. Clinical subsets in GCA present distinct complications and survival outcomes, with the cranial subset showing a higher incidence of severe ischemic events and the occult subset associated with delayed diagnosis and increased mortality. Recognizing these subsets is crucial for tailored treatment approaches and improving patient prognosis. Further prospective studies are needed to refine diagnostic and therapeutic strategies.

Pancreaticoduodenectomy in Patients With Coeliac or Superior Mesenteric Artery Stenosis: A Review of the Literature.

Pancreaticoduodenectomy (Whipple's procedure) is a technically demanding operation performed for malignant and premalignant conditions of the pancreatic head, duodenum and bile duct. Awareness of the vascular anatomy, variations, and pathology of this area is essential to achieve safe surgery and good outcomes. The operation involves division of the gastroduodenal artery (GDA) which provides communication between the foregut and midgut blood supply. In patients with coeliac or superior mesenteric artery (SMA) stenosis, this can lead to reduced blood supply to the foregut or midgut organs, with consequent severe ischaemic complications leading to significant morbidity and mortality. Coeliac artery stenosis is caused by median arcuate ligament syndrome (MALS) in the majority of patients with atherosclerosis being the second most common cause. SMA stenosis is much less common and is caused in the majority of cases by atherosclerosis. A review of preoperative imaging and intraoperative gastroduodenal artery clamp test is important to identify cases that may need additional procedures to preserve the blood supply. In this paper, we present a literature review for studies reporting patients undergoing Whipple's operation with concomitant coeliac axis stenosis (CAS) or SMA stenosis. Analysis of causes of stenosis or occlusion, prevalence, risk factors, different management strategies and outcomes was conducted.

Unveiling the Silent Constrictor: A Case Report of Takayasu Arteritis Manifesting as a Vascular Enigma

Introduction&#x0D; Takayasu arteritis (TKA) is a rare large vessel vasculitis, most prevalent in Asia and affecting females ages 10-40 years. Through unclear etiology, it triggers chronic granulomatous inflammation leading to vessel wall thickening, stenosis, and occlusion. Manifestations vary from mild malaise to severe ischemic complications. Diagnosis hinges on clinical criteria, including angiography, and exclusion of mimicking conditions like giant cell arteritis, fibromuscular dysplasia, or atherosclerosis. Treatment necessitates immunosuppression and anti-inflammatories to curb disease progression and limit complications.&#x0D; Case Presentation&#x0D; A 61-year-old Caucasian female presented with claudication of the upper extremities upon using the shower. She reported episodes of headache, myalgia, fever and chills of several months. She reported fatigue with overhead reaching and difficulty finding her pulse on her upper extremities. Labs were notable for elevated ESR and CRP. MRA chest showed smoky thickened appearance of the descending aorta wall, some missing wall thickening in origins of the left common carotid and left subclavian arteries. PET scan revealed diffuse hypermetabolic activity involving the bilateral common carotid arteries, peripheral aortic arch and descending thoracic aorta (Figure 1). With these ongoing symptoms and characteristic features on imaging, we established the diagnosis of TKA. She was started on 5mg oral prednisone daily and methotrexate 10mg weekly with daily folic acid.&#x0D; Conclusion&#x0D; This case highlights the diagnosis and treatment of a rare condition, Takayasu arteritis, the pulseless disease. TKA is a challenging condition to study and understand fully, but advancements in medical knowledge, imaging, and management are gradually improving our understanding and ability to diagnose and treat this condition. With increased awareness of this condition, earlier detection and monitoring will serve to benefit future patient populations.

A severe cerebral infarction associated with giant cell arteritis, which developed during tocilizumab therapy and was successfully treated with intravenous cyclophosphamide.

Giant cell arteritis (GCA) is a large vessel vasculitis that primarily involves aorta and its major branches. Cerebral infarction is a serious complication that can occur secondary to GCA in up to 3% of patients with a mortality rate of over 50%. Due to the rarity of this severe complication, no therapeutic strategies are currently available. Furthermore, despite the recent progress in molecular-targeted therapy for GCA, it remains unknown whether tocilizumab is effective for severe ischemic complications such as cerebral infarction. The accumulation of individual cases in which this fatal complication could be treated is apparently required to build a better management of the disease. We present our case of GCA that developed severe cerebral infarction during high-dose glucocorticoid and tocilizumab therapy, and its symptoms and image findings were improved by switching to intravenous cyclophosphamide. Our case suggests that an intensive immunosuppressive therapy, including cyclophosphamide, may be necessary to stabilise this fatal complication of GCA.

JS-NG-5: THROMBOTIC MICROANGIOPATHY OR MALIGNANT HYPERTENSION: WHICH COMES FIRST? A CASE REPORT FROM A TERTIARY CARE HOSPITAL

A 66-year-old woman with a history of arterial hypertension was admitted to the emergency department (ED) due to disorientation. She reported a severe headache, nausea, vomiting in the evening prior the admission; her blood pressure (BP) when the ambulance arrived was 220/100 mmHg. During admission, BP was 158/91 mmHg, pulse 95 beats/minute, oxygen saturation 88% on room air, body temperature 36.6°C. The urine examination showed that urine protein was 3+, red blood cell count 10 mg/L. The whole blood cell analysis revealed neutrophilic leukocytosis, thrombocytopenia (Table). There was 1 schistocyte seen in the peripheral blood smear. The serum creatinine and urea values were raised (Table) with elevated level of D-dimers (1690 mcg/L (&lt; 250 mcg/L)). Head CT showed no signs of hemorrhage or ischemia. Ceftriaxone, ampicillin, and acyclovir were initiated for suspected neuro-infection, she also underwent transfusion with 4 units of platelets due to thrombocytopenia. Patients GCS fell from 11 to 9 over 13 hours, therefore she was transferred to the intensive care unit (ICU). Cerebrospinal fluid analysis showed cytosis 15 cells/mcL (predominance of lymphocytes) and protein level of 1,073 g/L; PCR panel for the most common bacterial and viral meningitis agents came back negative. On day 2, lactate dehydrogenase level was raised at 3086 U/L (125–243 U/L), haptoglobin was &lt; 0.08 g/L (0.3–2.0 g/L) and Coombs test was negative. Due to worsening renal function (Table) hemodialysis was initiated. The differential diagnosis included thrombotic thrombocytopenic purpura, atypical hemolytic-uremic syndrome (HUS), secondary thrombotic microangiopathy (TMA), immune thrombocytopenic purpura (ITP) and disseminated intravascular coagulation (DIC). ADAMTS-13, CH50, SC5b-9 levels were tested (0.53 TV/ml (0.40–1.50 TV/ml), 60 U Eq/ml (55–75 U Eq/ml), 4689 ng/ml (200–325 ng/ml), respectively). The patient started on plasmapheresis. On day 3, fundoscopy showed cotton wool spots (ischemia) with hemorrhages and soft exudates next to the optic nerve disc; intravenous methylprednisolone pulse therapy was administered (1 g daily for three days followed by oral methylprednisolone 32 mg daily). Renal biopsy on day 5 revealed active TMA damaging the glomeruli and acute tubular necrosis. After 15 days in the ICU, she remained hypertensive and anuric despite given treatment. Moreover, pulmonary edema occurred on day 15. Malignant hypertension (MH) is characterized by severe hypertension and multi-organ ischemic complications. It can cause TMA and the overall presentation may imitate primary TMA. The approach of renal TMA in MH remains challenging. Herein, we reported a case of MHT with biopsy-proven TMA in the kidney.

Risks of posterior segment ocular ischaemic events in patients with systemic lupus erythematosus: a population-based cohort study in Taiwan

Backgroud/AimOcular involvement in systemic lupus erythematosus (SLE) is often primarily recognised by ophthalmologists rather than internists. This study aims to investigate the incidence and risk factors for the occurrence of...

Novel PET Imaging of Inflammatory Targets and Cells for the Diagnosis and Monitoring of Giant Cell Arteritis and Polymyalgia Rheumatica.

Giant cell arteritis (GCA) and polymyalgia rheumatica (PMR) are two interrelated inflammatory diseases affecting patients above 50 years of age. Patients with GCA suffer from granulomatous inflammation of medium- to large-sized arteries. This inflammation can lead to severe ischemic complications (e.g., irreversible vision loss and stroke) and aneurysm-related complications (such as aortic dissection). On the other hand, patients suffering from PMR present with proximal stiffness and pain due to inflammation of the shoulder and pelvic girdles. PMR is observed in 40–60% of patients with GCA, while up to 21% of patients suffering from PMR are also affected by GCA. Due to the risk of ischemic complications, GCA has to be promptly treated upon clinical suspicion. The treatment of both GCA and PMR still heavily relies on glucocorticoids (GCs), although novel targeted therapies are emerging. Imaging has a central position in the diagnosis of GCA and PMR. While [18F]fluorodeoxyglucose (FDG)-positron emission tomography (PET) has proven to be a valuable tool for diagnosis of GCA and PMR, it possesses major drawbacks such as unspecific uptake in cells with high glucose metabolism, high background activity in several non-target organs and a decrease of diagnostic accuracy already after a short course of GC treatment. In recent years, our understanding of the immunopathogenesis of GCA and, to some extent, PMR has advanced. In this review, we summarize the current knowledge on the cellular heterogeneity in the immunopathology of GCA/PMR and discuss how recent advances in specific tissue infiltrating leukocyte and stromal cell profiles may be exploited as a source of novel targets for imaging. Finally, we discuss prospective novel PET radiotracers that may be useful for the diagnosis and treatment monitoring in GCA and PMR.

Mathematical modeling of high-flow extra-intracranial bypass in the treatment of a complex cerebral aneurysm

Intracranial aneurysms (IAs) pose a high risk of spontaneous subarachnoid hemorrhage. In the most complex cases, the only way to exclude the aneurysm from the circulation is to perform a high-flow extracranial-to-intracranial bypass, thus creating a new bloodstream. This avoids severe ischemic complications; however, it requires careful consideration of individual anatomy and hemodynamic parameters. Computational fluid dynamics (CFD) can be of great help in planning such a surgery by creating 3D patient-specific models of cerebral circulation. Assessment of the perspectivity of high-flow extracranial-to-intracranial bypass planning using computational modeling. In this research work, we have applied the CFD methods to a patient with a giant thrombosed IA of the internal carotid artery (ICA). Preoperative CTA images and Gamma Multivox workstation were used to create a 3D model with current geometry and three additional models: Normal anatomy (no IA), Occlusion (with ligated ICA), Virtual bypass (with bypass and ligated ICA). The postoperative data were also available. Boundary conditions were based on PC-MRI measurements. Calculation of hemodynamics was conducted with a finite element package ANSYS Workbench 19. The results demonstrated an increase in the blood flow on the affected side by more than 70% after the virtual surgery and uniformity of flow distribution between the affected and contralateral sides, indicating that the treatment is likely to be efficient. Later, postoperative data confirmed that. The study showed that virtual preoperative CFD modeling could significantly simplify and improve surgical planning.

Vascular endothelial growth factor haplotypes are associated with severe ischaemic complications in giant cell arteritis regardless of the disease phenotype.

To determine whether functional vascular endothelial growth factor (VEGF) polymorphisms influence the expression of the clinical phenotype of giant cell arteritis (GCA). We also evaluated whether VEGF polymorphism is associated with the development of severe ischaemic manifestations in patients with GCA regardless of the clinical phenotype, classic cranial GCA or predominantly extracranial GCA large vessel vasculitis (LVV). VEGF rs833061 T/C, rs2010963 G/C and rs3025039 C/T polymorphisms were genotyped in 185 patients with biopsy-proven cranial GCA, 105 with extracranial LVV-GCA and 490 healthy controls. Allelic combinations (haplotypes) of VEGF were carried out. Comparisons were performed between patients with GCA and healthy controls as well as between patients with GCA stratified according to the clinical phenotype and the presence of severe ischaemic manifestations. No significant differences in genotype, allele, and haplotype frequencies of VEGF were found between patients with GCA and healthy controls as well as between GCA patients with the classic cranial pattern and the extracranial LVV-GCA pattern of the disease. However, the VEGF CGC haplotype (OR= 1.63 [1.05-2.53]) and the CGT haplotype (OR= 2.55 [1.10-5.91]) were significantly more frequent in GCA patients with severe ischaemic complications compared to those patients without these complications. VEGF haplotypes seem to play a role in the development of severe ischaemic manifestations in GCA patients, regardless of the clinical phenotype of expression of the disease.

The management of large vessel vasculitides

Giant cell arteritis (GCA) and Takayasu arteritis (TAK) represent the most common large vessel vasculitides (LVV). An early recognition of these conditions is crucial in order to start a prompt treatment to prevent severe ischemic complications, such as irreversible visual loss in GCA and cardiovascular or cerebrovascular accidents in TAK. Isolated glucocorticoids (GCs) still remain the cornerstone of GCA therapy. However, long-term treatment with GCs is burdened by an important toxicity. Furthermore, relapses are frequent during the follow-up period and relapsing patients have to cope with a longer duration of the GC therapy and a higher cumulative GC dose. On the other hand, TAK treatment usually relies on immunosuppressors in addition to GCs from the beginning. Also, since TAK patients are in general young women with a progressive disease, it is essential to treat this vasculitis with steroidsparing drugs in order to avoid excessive GC exposure. For this reason, efforts have been made to discover new therapeutic options able to reduce the cumulative GC dose that is strictly related to GC-toxicity. In recent years, new advances in the management of LVV have become available and have changed the therapeutic approach to these diseases. The aim of this review is to report new evidence of treatment efficacy and safety in LVV.

Choice of surgical treatment for slipped capital femoral epiphysis with severe chronic displacement of the epiphysis

Background. The spatial relationship between the epiphysis and the acetabulum in slipped capital femoral epiphysis (SCFE) with severe chronic epiphysis displacement is restored by different corrective extra-articular femoral osteotomies and a standard Dunn procedure. Severe residual deformity of the femoral component of the joint with symptoms of femoroacetabular impingement and a large number of severe ischemic complications forced the surgeons to improve the technique of these surgical interventions. In particular, a modified Dunn procedure was proposed using a low traumatic surgical hip dislocation. However, the selection of surgical treatment in these patients remains a subject of discussion.&#x0D; Aim. This study aimed to improve the results of treatment in children with SCFE with severe chronic epiphysis displacement.&#x0D; Materials and methods. Data of preoperative and postoperative clinical and radiological studies of 40 patients (24 male and 16 female) aged 1215 years who were suffering from SCFE with severe chronic epiphysis displacement were analyzed. In all cases, on the lesion side, displacement was found in typical directions (posterior-downward or only posterior), and in the contralateral joint, the disease was still at its initial stage (pre-slip). In group 1 (n = 20 children), a corrective extra-articular femoral (anterior-rotational or rotational-valgus) osteotomy was performed according to the method we have proposed in 2011 [22], and in group 2 (n = 20 children), the modified Dunn procedure that strictly followed our technique was performed. The follow-up period after surgery in both groups ranged from 1 month to 2.5 years.&#x0D; Results. At 2.5 years after surgery, good anatomical and functional outcomes were observed only in 1 (12.5%) of 8 patients in group 1, while they were observed in 7 (87.5%) of 8 patients in group 2. Poor results were determined by residual epiphyseal displacement (from 22 to 28) and/or step-like transition of the anterior femoral neck surface to the head in 5 (62.5%) children in group 1 and by femoral head avascular necrosis (diagnosed in 6 months after surgery) in 1 (12.5%) child in group 2.&#x0D; Conclusion. The results allow us to make a preliminary conclusion about the high efficiency of the modified Dunn procedure and the low efficiency of the corrective extra-articular femoral osteotomy in SCFE with severe chronic displacement of the epiphysis. The modified Dunn procedure corrects the pronounced deformity of the femoral component of the affected joint and femoroacetabular impingement in the above-mentioned anatomical situations.

PARTICULARITY OF HEMODYNAMICS IN HEMODIALYSIS PATIENTS WITH HAND ISCHEMIA

Introduction. Successful hemodialysis is impossible without effective vascular access. However, the average duration of its normal functioning is 2.53.0 years that is associated with complications, one of them is steal syndrome of the hand. Objective. To examine hemodynamic parameters in vascular access and forearm arteries in hemodialysis patients with hand ischemia. Methods. Duplex ultrasound was performed in 550 patients, 517 of which (94.0%) had an arteriovenous fistula, 33 (6.0%) had an arteriovenous graft. The inflow artery, anastomotic zone, outflow vein and arteries distal to the anastomotic zone were assessed during ultrasound examination, linear and volumetric speed indicators, peripheral resistance indices were measured. Results. Steal syndrome was detected in 2.7% of cases. The main reasons are the inflow artery alterations due to diabetes and atherosclerosis that lead to insufficient growth of blood flow through the artery (20,0%); huge anastomosis diameter that causes a vein dilation and significant increase in access flow (13,3%); insufficient blood flow through the ulnar, anterior interosseous arteries and the absence of collateral branches that did not compensate for retrograde blood flow in the radial artery distal to anastomosis (40,0%); microcirculatory dysfunction of the hand and alterations of the regulation mechanisms of the resistive vessels tone (26,7%). Conclusion. Dynamic ultrasound examination of vascular access can detect adverse changes in hemodynamics and avoid severe ischemic complications. The main reason of steal syndrome is the condition of the forearm arteries not participating in the fistula formation and the hand microvasculature.

Combined Antithrombotic Therapy in Patients with a Stable Atherosclerotic Cardiovascular Diseases: What Direction did COMPASS Show?

In patients with stable ischemic heart disease (IHD) and/or peripheral artery disease (PAD), current secondary prevention, including the antiplatelet monotherapy, is associated with a significant residual risk of recurrent cardiovascular complications (CVC). Practical application of results from many modern studies evaluating the effect of secondary prevention of atherothrombosis is complicated. An additional influence on coagulation may play a key role in prevention of atherothrombosis. In the COMPASS study, adding rivaroxaban 2.5 mg, b.i.d., to the acetylsalicylic acid (ASA) monotherapy significantly reduced the risk of death from cardiovascular complications, myocardial infarction or stroke, or all-cause death compared to the ASA monotherapy, in patients with IHD or PAD. The combination antithrombotic therapy was associated with an increased risk of major, but not fatal, or intracranial bleeding. In addition, PAD patients had a reduced risk of severe ischemic lower limb complications, including amputations. According to the subgroup analysis in the COMPASS study, supplementing ASA with rivaroxaban 2.5 mg, b.i.d., may appear most beneficial for patients with stable atherosclerotic disease and with a high risk of severe CVC without causing an increased risk of bleeding.

Risk factors for severe cranial ischaemic complications in giant cell arteritis.

Vision complications and a stroke represent severe cranial ischaemic complications (sCIC) associated with increased morbidity and mortality in GCA. We aimed to determine the risk factors for sCIC in GCA. We analysed the medical records of prospectively enrolled GCA patients diagnosed between September 2011 and August 2019, and compared the clinical and laboratory characteristics of patients with and without sCIC defined as either severe vision complications (diplopia, transient vision loss, permanent partial vision field/acuity defect and permanent visual loss) or stroke. During the 96-month observation period, we identified 295 new GCA patients [65.4% female, median (interquartile range) age 74.7 (67.3-80.0) years]. Sixty-one (20.7%) patients developed sCIC (52 isolated severe vision complications, 5 isolated ischaemic strokes and 4 patients with both complications). In a multivariable logistic regression model jaw claudication [odds ratio (OR) 3.43 (95% CI: 1.84, 6.42), P < 0.001], smoking [OR 1.92 (95% CI: 1.01, 3.65), P = 0.046] and increasing age [OR 1.08 (95% CI: 1.04, 1.13), P < 0.001] were significantly associated with sCIC. Higher CRP [OR 0.99 (0.99-1.00), P = 0.011] decreased the risk of sCIC. When considered separately, the odds for severe vision complications increased with age and jaw claudication, and decreased with polymyalgia rheumatica, constitutional symptoms and higher CRP. Atrial fibrillation emerged as the sole independent predictor of ischaemic stroke. Increasing age, jaw claudication and smoking predicted sCIC, while higher CRP decreased the risk of sCIC in our GCA cohort.

Should Tocilizumab Be Used Routinely in New Patients With a Diagnosis of Giant Cell Arteritis?

Should Tocilizumab Be Used Routinely in New Patients With a Diagnosis of Giant Cell Arteritis?

Severe ischemic complications in Covid-19—A case series

IntroductionCovid-19 has the propensity to result in a wide array of manifestations. Recently, thromboembolic complications of Covid-19 have been denoted in literature. We report 5 cases of Covid-19 positive patients with no significant comorbidities who developed 1st time episodes of either; acute limb ischemia or bowel ischemia. Material and methodsThis is a retrospective observational study analyzing the clinical characteristics and outcomes of five Covid-19 positive patients. Five patients aged 38–60 presented to our institution from 1st April to 1st June and were diagnosed with Covid-19 pneumonia, subsequently developing severe vascular complications. None of our patients included had any history of thromboembolism nor risk factors that could justify the presentations. Presentation of casesPatient 1; presented with bowel ischemia as a first presentation. Patient 2 and 3 developed unsalvageable lower limb ischemia secondary to partial to complete occlusion of infra-renal aorta. Patient 4 presented with acute upper limb ischemia due to complete occlusion of the axillary and brachial artery. Patient 5 developed bilateral lower limb unsalvageable ischemia secondary to aortic bifurcation occlusion. All patients tested Covid-19 positive upon admission, and received standard care. Discussion and conclusionThe thromboembolic complications seen in our cases were devastating and resulted in significant mortality and morbidity. All vessels affected were medium-large vessels. None of our cases had any significant predisposing medical conditions or history of thromboembolic or ischemic events. A high index of suspicion is necessary when evaluating such patients regardless of thromboembolic history. Appropriate anticoagulation regimens are essential. Our cases add to the currently increasing severe thromboembolic complications of Covid-19.

Midterm Results After Abandoning Routine Preemptive Coil Embolization of the Internal Iliac Artery During Endovascular Aneurysm Repair

Purpose: To analyze the results of endovascular repair of common iliac artery (CIA) aneurysms without preemptive coil embolization of the internal iliac artery (IIA). Materials and Methods: Between January 2010 and July 2016, 79 patients (mean age 74.3±8.4 years; 76 men) underwent endovascular repair extending into the external iliac artery owing to a CIA aneurysm. The procedure was performed for a ruptured aneurysm in 22 (28%) patients. Eighty-one IIAs were intentionally covered. The median CIA diameter was 37 mm (range 20–90). The primary outcomes were the occurrence of type II endoleaks and the incidence of buttock claudication. Results: Five (6%) patients died within 30 days (4 with ruptured aneurysms and 1 elective case). Two type II endoleaks originating from a covered IIA were recorded; one required an endovascular intervention because of aneurysm growth. The other patient died of a rupture based on an additional type III endoleak. Mean follow-up was 37.6±26.3 months. Nineteen (26%) patients required a secondary intervention. Buttock claudication was reported in 21 (28%) of 74 patients and persisted after 1 year in 7. No severe ischemic complications as a result of IIA coverage were recorded, and no revascularization was required during follow-up. Conclusion: Treatment of CIA aneurysms by overstenting the IIA without preemptive coil embolization is safe and has a low risk of type II endoleak and aneurysm growth. Persisting buttock claudication is rare.

Risk Factors Associated with Airway Complications after Lung Transplantation

Purpose This study aimed to classify and grade airway complications after lung transplant and to evaluate the risk of airway complications associated with antifibrotic use at a single lung transplant center. Methods All cases of lung transplantation at Barnes-Jewish Hospital between 1/1/2015 and 5/31/2018 were reviewed. Airway complications were graded using the 2018 ISHLT Consensus Statement on Adult Anastomotic Airway Complications. Antifibrotic use within 2 weeks of transplant was evaluated for association with airway complications by logistic regression. Results Based on the ISHLT Consensus definition, 159/261 patients (60.9%) had an airway complication; among these, only 20 (7.6%) were considered severe. There was no association between diagnosis for transplant and the development of an airway complication. AF use was associated with severe ischemic airway complication; among 58 who were on an AF agent pre-transplant, 8 (13.8%) developed an airway complication after transplant (odds ratio [OR] 2.547; 95% confidence interval [CI], 0.988 to 6.567; p = 0.053). This association was significant for nintedanib (OR 3.767; 95% CI, 1.119 to 12.681; p = 0.032) but not pirfenidone (OR 1.471; 95% CI, 0.465 to 4.660; p = 0.511). AF use was also associated with development of anastomotic stenosis; 14/58 (24.1%) developed anastomotic stenosis (OR 2.074; 95% CI, 1.004 to 4.283; p = 0.049). This association was not significant for nintedanib (OR 2.044; 95% CI, 0.693 to 6.022; p = 0.195) or pirfenidone (OR 1.781; 95% CI, 0.774 to 4.100; p = 0.175). AF use was not associated with anastomotic dehiscence; 8/58 (13.8%) developed a dehiscence (OR 1.139; 95% CI, 0.484 to 2.681; p = 0.765). Conclusion The grading system proposed by the 2018 ISHLT Consensus Statement led to identification of airway complication in >60% of lung transplants in this cohort, but most were considered mild and did not require intervention. Antifibrotic use was associated with increased risk of severe ischemic airway complications and anastomotic stenosis.