Stroke and Respiratory Failure: Mind the Shunt!

When stroke patients present with respiratory failure, the first thought that clinicians have is that it is probably related to aspiration pneumonia. However, other causes should be considered, such as intracardiac or intrapulmonary shunts, that could present with paradoxical embolism. Paradoxical embolism is a rare entity defined by the occurrence of a venous thrombotic event associated with a systemic arterial embolism. Frequently, paradoxical embolism presents with platypnoea-orthodeoxia syndrome. Platypnoea-orthodeoxia syndrome is uncommon and is characterized by dyspnoea and hypoxaemia induced by orthostatic position, where symptoms and oxygenation are relieved by recumbency. The authors report a case of a patient who presented with an ischaemic stroke and progression to platypnoea-orthodeoxia syndrome with documentation of simultaneous pulmonary embolism and pulmonary arteriovenous malformations.

Large-scale seroepidemiology identifies a nephro-vascular syndrome associated with autoimmune reactivity to tau

The microtubule-associated protein tau is involved in several neurodegenerative diseases and is currently being investigated as a plasma biomarker for the detection and monitoring of Alzheimer's disease and as an immunotherapeutical target in clinical trials. We assessed plasma anti-tau IgG reactivity in 40'098 unselected patients visiting a university hospital and healthy blood donors. We found that 4.97% patients and 1.58% healthy donors had natural anti-tau antibody titers >1.8 log10(EC50). In a multivariate model, female sex (P<0.001), age (P<0.001), cystitis (RR 1.59, 95%CI 1.14-2.16, P=0.004), other urinary disorders (RR 1.23, 95%CI 1.03-1.45, P=0.018), chronic kidney disease (RR 1.20, 95%CI 1.01-1.41, P=0.033), arterial embolism and thrombosis (RR 1.56, 95%CI 1.02-2.25, P=0.026) and atherosclerosis (RR 1.35, 95%CI 1.09-1.1.66, P=0.004) were independent predictors of anti-tau autoantibodies. We therefore conclude that anti-tau autoimmunity is associated with a systemic syndrome that includes vascular, kidney and urinary disorders. The expression of tau in these extraneural tissues suggests a potential role of autoimmunity in this syndrome.

The Correlation between Lower Extremity Fracture and Subsequent Arterial Embolism and Thrombosis—A National Population Cohort Study

The hazard of subsequent arterial embolism and thrombosis (SAET) in patients with lower leg fractures is not yet well demonstrated. The purpose of this study is to determine the correlation between lower leg fracture and SAET in Taiwan. A total of 134,844 patients with lower leg fractures (ICD-9-CM: 823) and chronological diagnosis as SAET (ICD-9-CM: 444.22) was matched (1:1) to the non-fracture cohort according to their propensity score (data coming from the National Health Insurance database between January 2000 to December 2012). Patients were matched by age, gender, and comorbidities. The incidence of SAET and correlation between SAET development and lower leg fracture was statistically analyzed, and subgroup analysis categorized by characteristics and comorbidities was conducted as well. The cumulative incidence of SAET was calculated by Kaplan–Meier analysis. Kaplan–Meier analysis plot showed that, by the end of the ten-year follow-up period, the cumulative incidence of SAET was significantly higher for the lower leg fracture cohort than for the non-fracture cohort (log-rank test: p < 0.001). The lower leg fracture, male, elder age (45–64-year-old; ≥65-year-old), hypertension, diabetes mellitus, and gout were significantly associated with lower extremity SAET risk compared with the matched group. There was an inseparable correlation between the lower leg fracture group and the risks of SAET; subgroup analysis by gender (male, female), age (age < 40 years, age 40–64 years, and age > 65 years) and comorbidities (hypertension, diabetes mellitus, and gout) show compatible results as well. Patients with lower leg fracture have a significantly increased risk of SAET since then two years after the fracture. The hazard of SAET was significantly higher in patients with lower leg fracture than in the non-fracture cohort, and the high incidence was found since then two years after fracture. Further studies are warranted.

CHARACTERISTICS OF PURULONECROTIC LESIONS IN COVID-19 PATIENTS

The COVID-19 pandemic has changed not only our social life, but also the course of many diseases, including purulent-inflammatory diseases of the lower extremities. The aim of the paper is to assess the influence of COVID-19 on purulonecrotic lesions of the lower extremities. Materials and Methods. We analyzed the results of treatment of 65 patients with purulonecrotic lesions of the lower extremities. All the patients were divided into 2 groups: Group 1 – 32 Non-COVID-19 patients, Group 2 – 33 COVID-19 patients. We studied laboratory blood parameters, hemostatic systems, performed lungs computed tomography (CT), and color-coded duplex scanning (CDS) of veins. Results. COVID-19 is more likely to affect patients aged 60–69 (51.5 %) and females (66.7 %). In Group 2 the level of leukocytes was higher than in Group 1 (11.2×109 and 13.9 109, respectively, p<0.05). Patients in both groups showed a tendency to hypercoagulability during anticoagulant therapy. In Group 2 patients, the percentage of transfemoral amputations was higher than in Group 1 patients (58 % and 18.8 % respectively). Arterial embolism of the lower limbs in Group 2 was observed in 6 % of patients. There were no deaths in Group 1, but in Group 2 mortality rate was 33.3 %. Conclusion. COVID-19 increases the number of arterial and venous thrombosis, often complicated by acute limb ischemia. Ischemic purulonecrotic processes complicated by COVID-19 are more severe, often lead to major limb amputation and are an important aggravating factor leading to death. Key words: COVID-19, purulonecrotic complications, coagulation, amputation. Пандемия COVID-19 не только внесла коррективы в социальную жизнь, но и изменила течение многих заболеваний, в т.ч. и гнойно-воспалительных поражений нижних конечностей. Цель. Оценить влияние коронавирусной инфекции на течение гнойно-некротических поражений нижних конечностей. Материалы и методы. Проведен анализ результатов лечения 65 больных с гнойно-некротическими поражениями нижних конечностей. Пациенты были разделены на 2 группы: 1-я группа – 32 больных без COVID-19, 2-я группа – 33 больных с COVID-19. Исследовались лабораторные показатели крови, системы гемостаза, проводились компьютерная томография легких, цветное дуплексное сканирование вен, анализировались результаты лечения. Результаты. COVID-19 чаще поражаются пациенты в возрасте 60–69 лет (51,5 %) и лица женского пола (66,7 %). У больных 2-й группы уровень лейкоцитов был выше, чем в 1-й группе (11,2×109/л и 13,9 ×109/л соответственно, р<0,05). На фоне антикоагулянтной терапии у больных обеих групп отмечалась тенденция к гиперкоагуляции. У больных 2-й группы ампутации на уровне бедра достигли 58 %, что более чем в 2 раза больше, чем у больных 1-й группы (18,8 %). Тромбоэмболии артерий конечностей во 2-й группе составили 6 %. Летальности в первой группе не было, во 2-й группе – 33,3 %. Выводы. Коронавирусная инфекция способствует возрастанию количества артериальных и венозных тромбозов, нередко осложняющихся острой ишемией конечностей. Ишемические гнойно-некротические процессы на фоне COVID-19 имеют более тяжелое течение, часто приводят к высокой ампутации конечности и являются важным отягощающим фактором, приводящим к летальному исходу. Ключевые слова: COVID-19, гнойно-некротические осложнения, коагуляция, ампутация.

Surgical Management of Acute Mesenteric Ischemia; Review Article

Mesenteric ischemia is a condition in which the amount of oxygen available is insufficient to meet the needs of the intestines. The small intestine, colon, or both can be affected by ischemia. The most common cause of occlusive ischemia is an abrupt obstruction of a major artery, which causes a considerable drop in intestinal blood flow. Early diagnosis is one of the most essential components in achieving a favorable outcome. The most prevalent treatment is surgical management. However, there are minimally invasive therapy alternatives that have been shown in observational studies. For arterial thrombosis, endovascular stenting is an option, and anticoagulation is an option for venous thrombosis. Endovascular aspiration, mechanical embolectomy, and local thrombolysis are all possibilities for patients with arterial embolism.

Concomitant pulmonary embolism and upper limb ischaemia as a first presentation of a patent foramen ovale

A 78-year-old female patient presented to the emergency department with syncope and dyspnoea. The left arm appeared to be cold and radial pulse was not palpable. A CT scan of the chest and left arm with intravenous contrast displayed bilateral central pulmonary embolisms in combination with a left subclavian artery embolism and an atrial septal aneurysm. Transthoracic echocardiography identified a patent foramen ovale with right-to-left shunting confirming the diagnosis of paradoxical embolism. The patient was treated with anticoagulants. In a patient presenting with a combination of a pulmonary embolism and a peripheral arterial embolism, the clinician should consider a right-to-left shunt with paradoxical embolism. In line with this, when diagnosing a peripheral arterial embolism, a central venous origin should be considered. Furthermore, when diagnosing a pulmonary embolism or other forms of venous thromboembolism, the clinician should be aware of signs of a peripheral arterial embolism.

Left Atrial Appendage Occlusion for Patients with Valvular Diseases: A Prospective Study Design

Background:As increasing evidence showed the efficacy of percutaneous left atrial appendage (LAA) occlusion in reducing the stroke risks in patients with non-valvular atrial fibrillation(AF), we design this study to quantify the effect of surgical LAA occlusion (SLAAO) for patients with valvular diseases and with or without AF.Methods:The current study will be implemented in two parts: Part 1 (AF study) is a prospective longitudinal study with a plan to consecutively register 2032 patients diagnosed with valvular diseases and AF and receiving cardiovascular surgeries. SLAAO will be performed at the individual surgeon’s preference. We centrally conducted a one-year follow-up on stroke, systemic arterial embolism, and all-cause mortality. Part 2 (non AF study) is a single-blinded, multicenter, randomized controlled trial with the purpose to evaluate the efficacy of SLAAO to reduce one-year embolism events in patients with valvular diseases, without AF, and receiving cardiovascular surgeries. 2118 patients will be randomized 1:1 to the intervention or control arm using a central randomization system.Results:The primary outcome is a composition of newly occurred ischemic stroke/transient ischemic attack (TIA) with positive neuroimaging or systemic arterial embolism, and cardiovascular mortality during one-year follow-up.Conclusion:The trial is designed to evaluate the efficacy of SLAAO to reduce embolism events one year after mitral or aortic surgeries, and this paper presents the prospective study protocol. It provides details of patient randomization, follow-up, methods of analysis of the material, and publication plan.

Acute myocardial infarction and arterial embolism in a patient with newly diagnosed renal mass: management dilemmas! A case report

Background Cancer is often associated with a hypercoagulable state and new thrombosis is often the first clinical manifestation of cancer. Surgical treatment of the primary tumor is crucial since it provides the only curative approach in most cases, but management of patients is highly complex, especially in the presence of new antiplatelet drugs and/or anticoagulants. Paraneoplastic syndromes (PNS) represent a frequent complication of renal cell carcinomas (RCC) and include different hematological symptoms in patients, whilst occlusion of arterial blood vessels displays a rare form of PNS accompanying renal tumors. Case presentation We report the case of a 62-year old man who was initially hospitalized due to acute coronary syndrome. He subsequently underwent coronary angioplasty treatment including multiple stenting and treatment with ticagrelor and aspirin. Post-interventional, acute arterial thrombotic emboli of several limb arteries required thrombectomy. By computer tomography we identified a renal lesion suspicious for an RCC and suspected a PNS as underlying cause of the thrombotic complications. Triple anticoagulant therapy was maintained with therapeutic dose low molecular weight heparin (LMWH), aspirin, and clopidogrel, by which we replaced ticagrelor. Surgery was postponed for 4 weeks. We paused LMWH, aspirin and clopidogrel only at the day of surgery and perioperatively restored hemostasis by transfusion of two platelet concentrates. Laparoscopic nephrectomy was uneventful. Pathology confirmed a clear cell RCC. The patient fully recovered whilst slowly reducing anticoagulation dose. Conclusions A multidisciplinary team approach of experts in urology, cardiology and hemostasis was key in managing this patient since a personalized thrombosis consult was needed to minimize the risk of reinfarction due to in-stent thrombosis. We report a therapeutic protocol that may be helpful for the management of similar cases. Furthermore, the finding of thrombotic arterial occlusions in larger blood vessels represents a novel complication of PNS in RCC and adds to the varied possible manifestations of this clinical chameleon.

Emergency care for patients with embolism of the aorta and main limb arteries in St. Petersburg: an analysis of 3498 cases over 50 years

The Objective was to study our treatment experience for the past 50 years of patients with acute embolism of the aorta and main arteries of the limbs (EAMAL).Methods and materials. We analyzed our treatment experience of 3498 patients with EAMAL over the past 50 years, from 1971 to 2020. All patients were treated at a single department. It was one of the first vascular surgery departments established in St. Petersburg. All patients were admitted to our clinic in an emergency way, all of them received urgent angiosurgical care.Results. 3091 (88.4 %) patients were operated on, in 2950 (95.4 %) cases the primary operation was revascularization (embolectomy), in 141 (4.6 %) – limb amputation. 2725 (77.9 %) patients were discharged from the hospital with a saved limb, another 160 (4.6 %) – after limb amputation, 614 (17.5 %) died. According to our findings, it was demonstrated that in recent decades there became significant changes in the ethiology of arterial embolism. Nowadays, 92.2 % of patients with EAMAL have atrial fibrillation as an independent disease or as a complication of another pathology. Over the past decades, the incidence of rheumatic heart disease as a direct cause of embolism has decreased by 8 times. Changes in the structure of embologenic diseases are associated primarily with an increase in the proportion of elderly and senile people suffering from severe concomitant diseases. In recent decades, there has been an increase in the number of patients with embolism of the distally located arteries, mainly of the brachial and popliteal arteries, and a decrease in the rate of embolism of the large arterial vessels – the aorta and iliac arteries. Modern approaches have made it possible to optimize treatment, stick to more aggressive tactics, improve surgical techniques, and thereby reduce the overall and postoperative mortality rate by more than 2 times, which is currently 9 % and 7.5 % respectively.Conclusion. Despite modern advances in vascular surgery, EAMAL remains the actual and complex problem of the health care system of St. Petersburg for the past 50 years.

Influence of thromboembolic events in the prognosis of COVID-19 hospitalized patients. Results from a cross sectional study

Background COVID-19 may predispose to both venous and arterial thromboembolism event (TEE). Reports on the prevalence and prognosis of thrombotic complications are still emerging. Objective To describe the rate of TEE complications and its influence in the prognosis of hospitalized patients with COVID-19 after a cross-sectional study. Methods We evaluated the prevalence of TEE and its relationship with in-hospital death among hospitalized patients with COVID-19 who were admitted between 1st March to 20th April 2020 in a multicentric network of sixteen Hospitals in Spain. TEE was defined by the occurrence of venous thromboembolism (VTE), acute ischemic stroke (AIS), systemic arterial embolism or myocardial infarction (MI). Results We studied 1737 patients with proven COVID-19 infection of whom 276 died (15.9%). TEE were presented in 64 (3.7%) patients: 49 (76.6%) patients had a VTE, 8 (12.5%) patients had MI, 6 (9.4%%) patients had AIS, and one (1.5%) patient a thrombosis of portal vein. TEE patients exhibited a diffuse profile: older, high levels of D-dimer protein and a tendency of lower levels of prothrombin. The multivariate regression models, confirmed the association between in-hospital death and age (odds ratio [OR] 1.12 [95% CI 1.10–1.14], p<0.001), diabetes (OR 1.49 [95% CI 1.04–2.13], p = 0.029), chronic obstructive pulmonary disease (OR 1.61 [95% CI 1.03–2.53], p = 0.039), ICU care (OR 9.39 [95% CI 5.69–15.51], p<0.001), and TTE (OR 2.24 [95% CI 1.17–4.29], p = 0.015). Conclusions Special attention is needed among hospitalized COVID-19 patients with TTE and other comorbidities as they have an increased risk of in-hospital death.