Clinical spectrum of ischaemic arterial diseases associated with COVID-19: a series of four illustrative cases

Abstract

Background: Severe coronavirus-induced disease 2019 (COVID-19) leads to acute respiratory distress syndrome with an increased risk of venous thrombo-embolic events. To a much lesser extent, arterial thrombo-embolic events have also been reported in this setting.

Case summary: Here, we describe four different cases of COVID-19 infection with ischaemic arterial events, such as a myocardial infarction with high thrombus load, ischaemic stroke on spontaneous thrombosis of the aortic valve, floating thrombus with mesenteric, splenic and renal infarction, and acute limb ischaemia.

Discussion: Cardiovascular risk factors such as hypertension, obesity, and diabetes are comorbidities most frequently found in patients with a severe COVID-19 infection and are associated with a higher death rate. Our goal is to provide an overview of the clinical spectrum of ischaemic arterial events that may either reveal or complicate COVID-19. Several suspected pathophysiological mechanisms could explain the association between cardiovascular events and COVID-19 (role of systemic inflammatory response syndrome, endothelial dysfunction, activation of coagulation cascade leading to a hypercoagulability state, virus-induced secondary antiphospholipid syndrome). We need additional studies of larger size, to estimate the incidence of these arterial events and to assess the efficacy of anticoagulation therapy.

Keywords: Acute coronary syndrome; Acute limb ischaemia; COVID-19; Case series; Stroke.

Figure 1

Computed tomography scan showing floating thrombus of the thoracic aorta.

Figure 2

Computed tomography scan showing left subclavian artery occlusion.

Figure 3

Computed tomography scan of floating thrombus (left arrow) with splenic (right arrow) and renal infarction.

Figure 4

Coronary angiogram, the arrow revealing an acute occlusion of the proximal left circumflex artery.

Figure 5

Coronary angiogram, the arrowrevealing an acute occlusion of the proximal left circumflex artery with a high thrombus load.

Figure 6

Computed tomography angiography scan of the cerebral arteries, the arrow showing occlusion of the M2 segment of the middle cerebral artery.

Figure 7

Two-dimensional transoesophageal echocardiography, the arrow showing vegetation appended to a cups of the aortic valve before anticoagulant treatment.

Figure 8

Two-dimensional transoesophageal echocardiography showing regression of vegetation appended to a cups of the aortic valve after anticoagulant treatment.