Diagnosis, Prevention, and Treatment of Thromboembolic Complications in COVID-19: Report of the National Institute for Public Health of the Netherlands

Abstract

A potential link between mortality, d-dimer values, and a prothrombotic syndrome has been reported in patients with coronavirus disease 2019 (COVID-19) infection. The National Institute for Public Health of the Netherlands asked a group of radiology and vascular medicine experts to provide guidance for the imaging work-up and treatment of these important complications. This report summarizes evidence for thromboembolic disease, potential diagnostic and preventive actions, and recommendations for prophylaxis and treatment of patients with COVID-19 infection.

Figure 1:

A schematic representation of the pathophysiological disease development of COVID-19, based on the results of the Wuhan population in the context of plasma D-dimer values, clinical and imaging characteristics (Clinical findings reconstructed from reference Zhou et al).

Figure 2:

Chest CT images in 51-year-old male patient presenting with progressive symptoms of cough and fever, proven COVID-19. (A) Day 7 after onset of symptoms: CT demonstrates bilateral ground glass opacities (GGOs) and early vascular enlargement. (B) Day 10: Rapid progression of GGOs with vascular thickening and interstitial pulmonary edema. (Figure courtesy of Department of Radiology, Haaglanden Medical Centre, The Hague, the Netherlands.)

Figure 3:

This proof of concept demonstrates CT perfusion findings in phase 1 in a 43-year old female patient proven COVID-19 with multiple ground glass opacities, with plasma Ddimer < 500 ng/ml and without pulmonary embolism on CT pulmonary angiography. There are multiple bilateral perfusion deficits due to microvascular obstruction, with increased blood flow in or adjacent to areas of ground glass opacities. The blood flow is slightly increased in the right lower lobe. Scan parameters: Conventional Dynamic Perfusion CT, Somatom Drive, Siemens; Scan volume 8,4 cm (aorta arch – left atrium); 1 mm recon; Dual input lung perfusion 4D, Vitrea, Vital, Canon; pulmonary flow: ml/min./100 ml; arterial flow: ml/min./100 ml; perfusion Index: % Baseline chest CT findings in selected slices (A, D), with perfusion index (B,E) and pulmonary arterial flow (C, F) in corresponding slices. (Figure courtesy of Department of Radiology, Haaglanden Medical Centre, The Hague, the Netherlands.)

Figure 4:

Plasma D-dimer course in 43 consecutive patients with COVID-19, admitted to the intensive care unit. PE was diagnosed with CTPA in 35 patients. (Figure courtesy of Dr Diederik Gommers, Erasmus University Medical Centre, Rotterdam, the Netherlands).