Intracranial Hemorrhage Associated with Therapeutic Anticoagulation in Three Critically Ill COVID-19 Patients: A Case Series

Introduction: The COVID-19 pandemic has challenged global health with novel pathogenesis that is both severe and poorly understood. Several mechanisms have been proposed to explain the severity and complexity of the clinical illness including cytokine storm release, thromboembolic microangiopathy, direct cytotoxicity, and post-viral bacterial super infection. Cases: The patients in this case series were all admitted to the intensive care unit with respiratory failure from COVID-19 requiring invasive mechanical ventilation. They were all started on anticoagulation. All three patients developed acute kidney injuries. The first patient had hypertensive emergency at the time of the bleed. The second and third patient both had supratherapeutic heparin levels at the time of the bleed. Methods: We followed patients aged 18 years and above who were admitted to the ICU for COVID-19 during April and May 2020. We then followed those who required therapeutic anticoagulation for any indication and evaluated the ones that developed ICH. Results: Out of the 79 patients admitted to the ICU for COVID-19 related illness during April and May 2020, 31 were placed on therapeutic anticoagulation (intermediate or full-dose) for indications that included hypercoagulable state, ACS, atrial fibrillation, and deep vein thrombosis. 25% of patients on anticoagulation developed bleeding for which the anticoagulation had to be stopped. Three out of these 31 patients developed ICH while on anticoagulation, accounting for 3.8% of our ICU population with COVID-19 Discussion: Activation of coagulation pathways during cytokine storms can result in systemic thromboembolism, in both venous and arterial circulations posing risk of ischemic infarctions to any organ. Supratherapeutic heparin levels and acute kidney injuries are common in COVID-19 patients. The ideal candidates for anticoagulation, the recommended agent and dose, and duration of treatment remain unclear. Conclusion: The benefits of anticoagulation should be weighed against the potential risk of bleeding.

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First-in-human experience of the Bashir Endovascular Catheter in the treatment of iliocaval deep vein thrombosis

Vascular Medicine ◽

10.1177/1358863x211028287 ◽

2021 ◽

pp. 1358863X2110282

Author(s):

Mohamad Al-Otaibi ◽

Neal B Shah ◽

Omer Iftikhar ◽

Prateek Sharma ◽

Koneti Rao ◽

...

Keyword(s):

Deep Vein Thrombosis ◽

Vena Cava ◽

Case Series ◽

The United States ◽

Bleeding Complications ◽

Vein Thrombosis ◽

Catheter Directed Thrombolysis ◽

Therapeutic Anticoagulation ◽

Catheter Design ◽

Deep Vein

Deep vein thrombosis (DVT) is a common disorder affecting approximately 900,000 new patients in the United States each year. Although the mainstay of treatment of DVT patients is therapeutic anticoagulation, some patients remain significantly symptomatic and therefore require more advanced interventions such as catheter-directed thrombolysis (CDT). We describe a case series of 13 patients with acute symptomatic inferior vena cava (IVC) and iliofemoral DVT that were treated with CDT using the Bashir Endovascular Catheter (BEC). We report the first-in-human use of BEC, which is a novel pharmacomechanical thrombolysis device. All the treated patients had complete and rapid resolution of their symptoms with excellent venous outflow. Despite initial promising results, larger studies using this catheter design will be needed to assess the role of BEC-directed therapy on rates of post-thrombotic syndrome and bleeding complications.

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Thrombus risk versus bleeding risk: a clinical conundrum

BMJ Case Reports ◽

10.1136/bcr-2018-228344 ◽

2019 ◽

Vol 12 (3) ◽

pp. e228344

Author(s):

Elisabeth Ng ◽

Adel Ekladious ◽

Luke P Wheeler

Keyword(s):

Aortic Dissection ◽

Bleeding Risk ◽

Pressure Control ◽

Lower Limbs ◽

Vein Thrombosis ◽

Pulmonary Angiogram ◽

Therapeutic Anticoagulation ◽

Apex Beat ◽

The Right ◽

Deep Vein

A 62-year-old man presented to the Emergency Department with dyspnoea and central pleuritic chest pain radiating posteriorly to between the scapulae. His medical history included hypertension, osteoporosis and chronic kidney disease secondary to focal segmental glomerulosclerosis with relapsing nephrotic syndrome. Significant examination findings included a loud palpable P2 and a displaced apex beat. An ECG revealed sinus tachycardia with a right-bundle branch block and p-pulmonale. A CT pulmonary angiogram and aortogram demonstrated extensive bilateral pulmonary emboli and a descending thoracic aortic dissection. Subsequent ultrasound of the lower limbs confirmed an extensive, non-occlusive deep vein thrombosis in the right calf. Management of this patient involved therapeutic anticoagulation and tight blood pressure control, with plans for surgical repair delayed due to worsening renal impairment and subsequent supratherapeutic anticoagulation. Co-existence of an aortic dissection and PE has been rarely described and optimal management remains unclear.

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Sonographic and Clinical Features of Upper Extremity Deep Venous Thrombosis in Critical Care Patients

Critical Care Research and Practice ◽

10.1155/2012/489135 ◽

2012 ◽

Vol 2012 ◽

pp. 1-8 ◽

Cited By ~ 2

Author(s):

Michael Blaivas ◽

Konstantinos Stefanidis ◽

Serafim Nanas ◽

John Poularas ◽

Mitchell Wachtel ◽

...

Keyword(s):

Risk Factors ◽

Critical Care ◽

Upper Extremity ◽

Strong Predictor ◽

Venous Catheter ◽

Acute Thrombosis ◽

Vein Thrombosis ◽

Therapeutic Anticoagulation ◽

Deep Vein ◽

Critical Care Patients

Background-Aim. Upper extremity deep vein thrombosis (UEDVT) is an increasingly recognized problem in the critically ill. We sought to identify the prevalence of and risk factors for UEDVT, and to characterize sonographically detected thrombi in the critical care setting.Patients and Methods. Three hundred and twenty patients receiving a subclavian or internal jugular central venous catheter (CVC) were included. When an UEDVT was detected, therapeutic anticoagulation was started. Additionally, a standardized ultrasound scan was performed to detect the extent of the thrombus. Images were interpreted offline by two independent readers.Results. Thirty-six (11.25%) patients had UEDVT and a complete scan was performed. One (2.7%) of these patients died, and 2 had pulmonary embolism (5.5%). Risk factors associated with UEDVT were presence of CVC [(odds ratio (OR) 2.716,P=0.007)], malignancy (OR 1.483,P=0.036), total parenteral nutrition (OR 1.399,P=0.035), hypercoagulable state (OR 1.284,P=0.045), and obesity (OR 1.191,P=0.049). Eight thrombi were chronic, and 28 were acute. We describe a new sonographic sign which characterized acute thrombosis: a double hyperechoic line at the interface between the thrombus and the venous wall; but its clinical significance remains to be defined.Conclusion. Presence of CVC was a strong predictor for the development of UEDVT in a cohort of critical care patients; however, the rate of subsequent PE and related mortality was low.

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Special Conditions in Venous Thrombembolism – Case Series

PRILOZI ◽

10.2478/prilozi-2019-0021 ◽

2019 ◽

Vol 40 (2) ◽

pp. 103-111

Author(s):

Marijan Bosevski ◽

Irena Mitevska ◽

Marica Pavkovic ◽

Milka Klincheva ◽

Emilija Trajkovska Lazarova ◽

...

Keyword(s):

Randomized Clinical Trials ◽

Real Life ◽

Case Series ◽

Vascular Diseases ◽

The Elderly ◽

Hospital Death ◽

High Risk Population ◽

Vein Thrombosis ◽

Cancer Associated Thrombosis ◽

Deep Vein

Abstract Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), is a preventable cause of in-hospital death, and one of the most prevalent vascular diseases. There is a lack of knowledge with regards to contemporary presentation, management, and outcomes of patients with VTE. Many clinically important subgroups (including the elderly, those with recent bleeding, renal insufficiency, disseminated malignancy or pregnant patients) have been under-represented in randomized clinical trials. We still need information from real life data (as example RIETE). The paper presents case series with VTE in special conditions, including cancer associated thrombosis, malignant homeopathies, as well in high risk population.

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Abstract 11662: Obesity Does Not Increase Venous Thromboembolism in Hospitalized Medical Patients Upon Multivariate Analysis

Circulation ◽

10.1161/circ.130.suppl_2.11662 ◽

2014 ◽

Vol 130 (suppl_2) ◽

Author(s):

Gabriel V Fontaine ◽

Emily Vigil ◽

Paul Wohlt ◽

David Collingridge ◽

James F Lloyd ◽

...

Keyword(s):

Venous Thromboembolism ◽

Primary Outcome ◽

Univariate Analysis ◽

Obese Patients ◽

Medical Patients ◽

Vte Prophylaxis ◽

Vein Thrombosis ◽

Therapeutic Anticoagulation ◽

Comorbidity Index ◽

Deep Vein

Introduction: Obesity increases the risk of venous thromboembolism (VTE) in hospitalized medical patients. Standard chemoprophylaxis in these patients may be suboptimal, potentially leading to increased VTE. The objective of this study was to compare the rate of VTE in obese (body mass index [BMI] ≤30 kg/m 2 ) medical patients receiving standard VTE prophylaxis with rates in non-obese patients (BMI 17-29.9 kg/m 2 ). Hypothesis: Obese patients will suffer from a higher incidence of VTE within 90 days of hospitalization. Methods: In a single-center retrospective cohort study, patients admitted to all medical units between November 2007 and November 2013 were evaluated for eligibility if they received an initial dose of VTE prophylaxis within 48 hours of admission. Appropriate prophylaxis was heparin 5000 units subcutaneously (SQ) every 8 to 12 hours or enoxaparin 30 mg SQ twice daily or 40 mg SQ once daily. Exclusion criteria included hypercoagulable states, therapeutic anticoagulation, and admission for trauma or surgery. The primary outcome was 90 day VTE defined as deep vein thrombosis or pulmonary embolism using ICD-9 codes. Secondary outcomes included in-hospital VTE, 30 day VTE, and 90 day mortality. Univariate and multivariate analyses were used in calculating p-values and odds ratios (OR) for the primary outcome. Results: There were 17,525 patients eligible for inclusion. The final cohort included 4,237 obese patients and 4,990 non-obese patients (median BMI 36 and 25 kg/m 2 , respectively). Obesity increased the risk of in-hospital VTE (5.6% vs. 4.4%; p=0.01), 30 day VTE (5.7% vs. 4.6%; p=0.013), and 90 day VTE (5.9% vs. 4.8%; p=0.028) on univariate analysis. However, using multiple logistic regression, obesity was not an independent predictor of 90 day VTE (OR 1.0; p=0.83). Variables which independently increased 90 day VTE were Charlson Comorbidity Index (OR 1.09; p=0.003), prior VTE (OR 36.35; p<0.001), congestive heart failure (OR 1.33; p=0.017), and surgery in 90 days following admission (OR 1.56; p=0.004). Mortality was lower at 90 days in obese patients (3.3% vs. 6.3% non-obese; p<0.001) Conclusions: The incidence of VTE at 90 days in hospitalized medical patients is significant, but it is uncertain if obesity independently contributes to this.

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Duration of Treatment of Deep Vein Thrombosis: Time for a New Approach?

Pharmacotherapy The Journal of Human Pharmacology and Drug Therapy ◽

10.1592/phco.2005.25.8.1112 ◽

2005 ◽

Vol 25 (8) ◽

pp. 1112-1115

Author(s):

Paula G. Rychlik ◽

Karol S. Henry ◽

Henry I. Bussey

Keyword(s):

Deep Vein Thrombosis ◽

Duration Of Treatment ◽

New Approach ◽

Vein Thrombosis ◽

Deep Vein

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H1N1-Induced Venous Thromboembolic Events? Results of a Single-Institution Case Series

Open Forum Infectious Diseases ◽

10.1093/ofid/ofw214 ◽

2016 ◽

Vol 3 (4) ◽

Cited By ~ 6

Author(s):

Evangelos Dimakakos ◽

Dimitra Grapsa ◽

Ioannis Vathiotis ◽

Aggeliki Papaspiliou ◽

Meropi Panagiotarakou ◽

...

Keyword(s):

Influenza A ◽

Case Series ◽

Thromboembolic Events ◽

Vein Thrombosis ◽

Imaging Characteristics ◽

Influenza A H1n1 ◽

Venous Thromboembolic Events ◽

Venous Thromboembolic ◽

Deep Vein ◽

Novel Influenza A

Abstract We describe the clinical and imaging characteristics of 7 cases with polymerase chain reaction-confirmed novel influenza A H1N1 virus (pH1N1) infection who developed venous thromboembolic events (VTEs) while being hospitalized for influenza pneumonia. Pulmonary embolism (PE) without deep vein thrombosis (DVT) was observed in 6 of 7 cases (85.7%); PE with underlying DVT was found in 1 patient (14.3%).

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AB0713 Interferon-alpha for the management of lower extremity deep vein thrombosis in behcet’s syndrome: a case series

10.1136/annrheumdis-2018-eular.7197 ◽

2018 ◽

Cited By ~ 2

Author(s):

Y. Ozguler ◽

G. Hatemi ◽

F. Cetinkaya ◽

K. Tascilar ◽

S. Ugurlu ◽

...

Keyword(s):

Deep Vein Thrombosis ◽

Lower Extremity ◽

Interferon Alpha ◽

Case Series ◽

Behçet’S Syndrome ◽

Behçet's Syndrome ◽

Vein Thrombosis ◽

Behcet’S Syndrome ◽

Deep Vein ◽

Behcet's Syndrome

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Should we diagnose and treat distal deep vein thrombosis?

Hematology ◽

10.1182/asheducation-2017.1.231 ◽

2017 ◽

Vol 2017 (1) ◽

pp. 231-236 ◽

Cited By ~ 10

Author(s):

Helia Robert-Ebadi ◽

Marc Righini

Keyword(s):

Deep Vein Thrombosis ◽

Statistical Power ◽

Medical Condition ◽

Low Risk ◽

Vein Thrombosis ◽

Randomized Studies ◽

Therapeutic Anticoagulation ◽

Risk Patients ◽

Distal Deep Vein Thrombosis ◽

Deep Vein

Abstract Ultrasound series report that isolated distal deep vein thrombosis (DVT), also known as calf DVT, represents up to 50% of all lower-limb DVTs and, therefore, is a frequent medical condition. Unlike proximal DVT and pulmonary embolism, which have been studied extensively and for which management is well standardized, much less is known about the optimal management of isolated calf DVT. Recent data arising from registries and nonrandomized studies have suggested that most distal DVTs do not extend to the proximal veins and have an uneventful follow-up when left untreated. These data had some impact on the international recommendations that recently stated that ultrasound surveillance instead of systematic therapeutic anticoagulation might be an option for selected low-risk patients. However, robust data from randomized studies are scarce. Only 5 randomized trials assessing the need for anticoagulation for calf DVT have been published. Many of these trials had an open-label design and were affected by methodological limitations. The only randomized placebo-controlled trial included low-risk patients (outpatients without cancer or previous venous thromboembolism [VTE]) and was hampered by limited statistical power. Nevertheless, data from this trial confirmed that the use of therapeutic anticoagulation in low-risk patients with symptomatic calf DVT is not superior to placebo in reducing VTE but is associated with a significantly higher risk of bleeding. Further randomized studies are needed to define the best therapy for high-risk patients (inpatients, patients with active cancer, or patients with previous VTE) and the optimal dose and duration of treatment.

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