Acute Limb Ischemia in One Dose Vaccination of COVID-19

Introduction: The extraordinary thrombotic manifestations of Corona virus Disease-2019 (COVID-19) caused by Severe Acute Respiratory Syndrome CoV-2 (SARS-CoV-2) virus, presenting as venous and arterial thrombosis have been reported in several literatures, but in this report, we presented a special case of acute limb ischemia in a patient that has been vaccinated by COVID-19 vaccine. Acute limb ischemia (ALI) is defined as decreasing in arterial perfusion of a limb with a threat to viability of the limb and mortality. COVID-19 has been declared as a global pandemic by the WHO. Patients with COVID-19 have abnormalities in blood coagulation parameters and are prone to thromboembolic events. This hypercoagulable state caused by COVID-19 mainly manifests as venous thromboembolism while peripheral arterial involvement is less frequent. Case: A 54-year diabetic and smoker male has already got one dose COVID-19 vaccination came to our emergency unit with severe acute respiratory syndrome and pain, pale and paresthesia of his left leg. There was pneumonia pattern according to chest X-ray and a ground glass opacity in chest CT-scan, he was confirmed infected by COVID-19 according to RT-PCR test. From CT-Angiography we found multiple thrombosis in the distal aorta, superficial femoral artery (SFA), anterior tibial artery (ATA), and posterior tibial artery (PTA) of left lower extremity. Initial treatment we started with unfractionated heparin, oxygenation, intravenous fluid and analgesia. We managed the patient in isolation ward special for COVID-19. We did thrombectomy to save the limb, nevertheless in few days after we performed amputation at the level of talonavicular joint to the distal part of left foot caused by gangrene. Conclusion: Vaccination can protect from COVID-19 if we vaccinated with full dose and our immune system able to create antibody. The condition will be different in immunocompromised condition and we get not full dose vaccination. Covid-19 Patient with Diabetes and smoker could have higher risk to develop acute limb ischemia because of hypercoagulable state. Management of a COVID-19 patient with cute limb ischemia is more complicated and challenging. Although we have already vaccinated life style modification like wearing a mask, social distancing and using hand sanitizer can give us more protection from Covid 19. Keywords: acute limb ischemia, COVID-19 vaccination, heparinization, thrombectomy

Optimal Time of Extraction Retrievable Inferior Vena Cava Filters in Venous Thromboembolic Treatment: Evidence Based Case Report

Background: Inferior vena cava (IVC) filters have been proven to be significantly advantageous and clinically efficacious in the prevention of deathly venous thromboembolism, but also carry long-term risks, such as device failure, filter fracture, migration, penetration into adjacent structures, etc. Retrievable filters offer the same degree of protection, and subsequently lower those risk by removing them after they aren’t needed. Unfortunately, increasing use of retrievable filters leads to one alarming trend: there’s massive number of filters that are left for an extended time. Whether the time between deployment and retrieval affects filter’s technical success of retrieval remains questionable. Here is a case of a 45-year old woman who had undergone retrievable IVC filter due to pulmonary embolism risk. The patient only came to clinician for routine follow- up once, one month after deployment. One year later, the patient felt abdominal pain and asked to remove the filter. After one failed attempt, the clinician decided to leave the filter in situ as permanent filter. Method: Literature searching was conducted in several databases (ScienceDirect, EbscoHost, and ClinicalKey) using specified keywords. Six articles that had been passed exclusion and inclusion criteria, were eventually appraised and extracted. Results: Of all six articles that are included in this study, there are no standard time of retrieval. Each study provides data regarding their attempted retrieval, successful retrieval, and dwell time. Only two articles (Uberoi et al and Glocker et al) analyze the relationship between time of retrieval and successful retrieval. Uberoi et al claims filter retrieval statistically more successful if the dwell time is less than 9 weeks, whereas Glocker et al states the procedure is considerably more successful within 3-4 months (117 days) after deployment. The reasons of retrieval failure in these studies are varied, including device angulation, filter incorporation with IVC wall, and penetration to IVC wall and adjacent structures, or significant thrombus inside the filter. Conclusion: There are no standard time of retrieval, but clinicians could follow FDA recommendation by removing the filter when it isn’t necessarily needed. However, a time span of 3-4 months between implantation and retrieval can be respectable choice to make sure the maximum chance at retrieval success.

Effect of Venoplasty on Arteriovenous Fistula Dysfunction on Quick of Blood Values of Hemodialysis Patients

Introduction: Percutaneous transluminal angioplasty (PTA) is the gold standard in the management of AVF dysfunction. On the other hand, the management of stenosis with PTA induces an acceleration of neointimal hyperplasia with the occurrence of restenosis. The aim of this study was to assess the increase of quick of blood (Qb) hemodialysis (HD) patients after venoplasty with AVF dysfunction and its patency within 3 months post procedure, and examine the factors associated with venoplasty failure to maintain optimal Qb. Method: This study used a quasi-experimental design, in which all subjects received the treatment under study without a control group, due to ethical issues; because venoplasty is the standard protocol for AVF dysfunction in the place of this study. Qb measurements were made before and after HD, and 3 months thereafter, to evaluate AVF patency. Result: There were 25 cases that included 23 patients with 2 patients had to be re- venoplasty. An increase in Qb averaged 221.3−196.7 mL / min or about 25 mL / min in the 3-month period after venoplasty with significant results (p = 0.044). The location of stenosis in juxta anastomosis has a 14 times greater chance of venoplasty failure (p = 0.037) than stenosis in the area of draining vein or central vein. Diabetes Mellitus (DM) increased the odds of venoplasty failure 12 times greater (p = 0.038) than cases without this comorbid.. Conclusion: This study proves the increase in Qb of hemodialysis patients after venoplasty for AVF dysfunction, and it was found that the location of juxta anastomosis stenosis and the presence of DM are the two main factors that have the potential to increase the chance of venoplasty failure.

Screening Recommendations for Asymptomatic Carotid Artery Disease and Role of Carotid Intima-Media Thickness Evaluation: A Literature Review

Background: Asymptomatic carotid artery disease should be treated as soon as possible before the atherosclerotic disease progressed into ischaemic stroke. Diagnostic screening by measuring intima-media thickness (IMT) of carotid artery using ultrasound is one possible way to evaluate earlier the progression compared to standard stenosis evaluation. Not only the necessity of carotid screening is still questioned by some experts, current guidelines also show conflicting results in certainty whether we should perform the carotid screening or not. It is necessary to conduct a literature review of relevant recommendations from the latest clinical practice guidelines (CPGs). Method: The CPGs on the management of asymptomatic carotid artery disease published before October 2020 were retrieved from online databases and the rigor of guideline development assesed by using the Appraisal of Guidelines Research and Evaluation II (AGREE-II) instrument. The quality of CPGs was assessed and categorized, and their reported evidences were also evaluated. Results: Six eligible CPGs were included. Five of the CPGs recommends carotid screening for highly selective patient who has morbidity regarding atherosclerotic disease manifested in other organs. One CPG against the screening as further treatment considered cause more harms, although the recommendations mainly based on hypothetical outcomes and the CPG itself categorized into moderate quality. Conclusion: Our critical review on those CPGs showed that screening for asymptomatic carotid artery disease should be performed for specific high-risk populations of atherosclerotic disease. Although IMT evaluation could be a promising technique, current guidelines didn’t show any recommendation regarding the usage comparing standard ultrasound evaluation.

Bloodstream Infection of Double Lumen Catheter among Hemodialysis Patient

Background: Infection is one of complication of vascular access that can lead a higher morbidity, loss of access, and even mortality. Hospitalized hemodialysis patients with double lumen catheter (DLC) have a two to three higher risk for infection and death compared to patients with arteriovenous graft. The aim of this study was to determine the infection rate in dialysis double lumen catheter and its characteristic. Method: A retrospective study was conducted in Sanglah General Hospital. Inclusion criteria was patients aged ≥18 years old who required DLC for hemodialysis access during April 2017 to March 2018. Exclusion criteria were patients without blood culture result and incomplete medical report. Data presented in a demographic data, including microbial pattern of bloodstream culture. Result: Among 42 patients who was diagnosed with bacteremia (41.2%), 57% were male, and mostly using non-tunneled DLC. Coagulase-negative Staphylococci (23.8%) was the commonest pathogen of infected DLC, followed by Staphylococcus aureus (9.5%) and Staphylococcus epidermidis (7.1%). Pseudomonas aeruginosa and Acinetobacter baumanni, and nosocomial pathogen was counted for 4,8 %. Conclusion: Infection rate in DLC among hemodialysis patients of Sanglah General Hospital was 28.6% with the most common etiology was Coagulase-negative Staphylococci (23.8%).

PEDIS Score Analysis in Diabetic Foot Ulcer following Angioplasty Revascularization Procedure

Background: Diabetic foot ulcers (DFU) is one of the major health care problems. Diabetic foot ulcers are a combination of vascular and non-vascular disorders. Vascular disorders that occur in the form of diabetic angiopathy which can be in the form of macro angiopathy if the condition occurs in large blood vessels, and micro angiopathy if it occurs in arterioles and capillaries. Revascularization can be done minimally invasive and has become the gold standard in the management of chronic limb ischemic (CLI). WHO recommends Perfusion, Extent / Size, Depth / Tissue Loss, Infection, Sensation (PEDIS) classification to diagnose and to determine the management of diabetic foot. We conduct a study to find out whether there are improvements in the PEDIS score of diabetic foot ulcer patients post angioplasty Methods: This study was designed in the form of a quasi-experiment, in which measurements before and after treatment were carried out on patients with diabetic foot ulcers (DFU) who underwent revascularization angioplasty without any measurement for control patients. From November 2019 to September 2020, there were 48 cases of diabetic foot ulcer with peripheral artery disease (PAD) who underwent angioplasty. Before the procedure, a clinical evaluation and calculation of the PEDIS score were carried out then angioplasty was performed, after the procedure the PEDIS score was calculated and evaluated in the first, second and third weeks. Results: The PEDIS scores of the patients prior to angioplasty had a median score of 8 (IQR 7; 9). Post-procedure the median quantity fell to 6 on both the immediate post angioplasty and two weeks afterward measurement with the width of the IQR narrowing slightly at the last measurement. The male patients’ PEDIS scores did not differ relatively from those of the female patients at the three measurement times, and their scores were almost identical to the scores for the patients as a whole. Conclusion: The results of this study indicate that there is an improvement in the PEDIS score in diabetic foot ulcer patients after revascularization angioplasty.

Correlation Between Preoperative Vein Distensibility With Radiocephalic Arteriovenous Fistula Maturation in Patients With End Stage Renal Disease

Introduction: Patients with end stage renal disease require hemodialysis. Radiocephalic arteriovenous fistula is the main choice of vascular access in patients who undergo hemodialysis procedure. Physiological vein distensibility is an important aspect in forming a mature arteriovenous fistula. This study aims to analyze the correlation between preoperative distensibility and arteriovenous fistula maturation. Method: Data are collected from end stage renal disease patients in Hasan Sadikin Hospital and RA Habibie Hospitals that will go through radiocephalic arteriovenous fistula procedure during the period of October 2018 to February 2019. Vein distension procedure is performed before the operation and maturation is evaluated four to six weeks after the operation. The comparison of preoperative venous distensibility in two different groups of arteriovenous fistula maturation category is analyzed using chi square test model. Result: This study found that preoperative venous distensibility value affects arteriovenous fistula maturation with a statistical significance (p-value = 0.007), yielding a contingency coefficient of 0.553, and a very strong relation value of 0.782. Conclusion: Preoperative vein distensibility of more than 30% is predictive of successful arteriovenous maturation.

Comparison Between Wells’ Criteria and Khorana Score in Detecting Asymptomatic Deep Vein Thrombosis in Colorectal Cancer Patients in Dr. Hasan Sadikin Hospital

Background: Deep vein thrombosis is a blood clot that occurs in the deep veins. Fifty percent of patients with deep vein thrombosis do not show clinical symptoms. The incidence of deep vein thrombosis in colorectal cancer patients is higher than in other cancer patients. Several scoring system models, such as Wells’ criteria and Khorana score, were developed to help diagnose deep vein thrombosis . Methods: This study was a prospective observational analytic with cross sectional design that compared the Khorana score with Wells’ criteria in predicting the occurrrence of asymptomatic deep vein thrombosis in colorectal cancer patients. Comparisons were made using Chi Square analytical test and diagnostic tests. Results: A total of 63 patients were obtained. Using Wells’ criteria, 55 patients (87.3%) fell into the mild risk category, 8 patients (12.7%) in the moderate risk category and no patients in the high risk category. Using Khorana score, 35 patients (55.6%) fell into the mild risk category, 28 (44.4%) patients in the moderate risk category, and no high risk category patients were found. There were 14 patients (22.2%) with asymptomatic deep vein thrombosis and 49 patients (77.8%) without deep vein thrombosis. Comparison of the proportion of Wells’ criteria with asymptomatic patients has a p-value of 0.48, while Khorana score with asymptomatic patients has a p-value of 0.001. Conclusion: Khorana score is better than Wells’ criteria in detecting asymptomatic deep vein thrombosis in colorectal cancer patients.

LMWH Treatment in Patients with Cancer Diagnosed with Venous Thromboembolism

Venous thromboembolism (VTE) is associated with increased mortality and morbidity in cancer patients, and VTE development is among the most frequent causes of death in cancer patients. In this study, we evaluated the efficacy of enoxaparin and tinzaparin on thrombosis development in 36 cancer patients. Of 36 the cases, 14 were given enoxaparin (single dose, 6000 anti-Xa/0.6 ml, s.c.), and 22 were given tinzaparin (single dose 20.000 IU/0.7 ml, s.c.). The improvement was observed following the treatment in Doppler ultrasonography and the resolution of VTE was clinically detectable. We did not observe any signs of a new thrombus development or bleeding in the patient group. We detected a longer survival time in patients with enoxaparin treatment (p<0.05). We conclude that low-molecular-weight heparins are an efficient treatment method for VTE in cancer patients.

Sensitivity and Specificity of Ankle Brachial Index (ABI) and Pulse Wave Handheld Doppler (PWHD) Compared with Angiography as Diagnostic Test for Patients with Peripheral Artery Disease (PAD)

Background: Peripheral artery disease (PAD) is a clinical condition that occurs due to atherosclerosis and narrowing of the arteries involving the aorta, branches of the visceral arteries such as the iliac arteries, and the arteries of the distal extremities. The femoropopliteal artery is the most commonly involved site in patients with atherosclerotic PAD. Ankle Brachial Index (ABI) determination may have limited value in some patients with diabetes, because calcification of the tibial artery can render it uncompressible, resulting in a very high ABI value (>1.40). Handheld vascular Doppler with pulse volume waveform interpretation (PVW) is an easily available and non-invasive modality for evaluation of the inferior extremity arteries and can detect the severity of blood flow disturbances or ongoing PAD. The best diagnostic method for PAD is angiography using digital substraction angiography (DSA) to assess existing atherosclerotic lesions. The advantages of ABI and PWHD examinations are in terms of simplicity, ease of use, and non-invasiveness instead of angiography in PAD diagnosis led the investigators to compare the sensitivity and specificity values between ABI and PWHD with angiography as a diagnostic test for PAD patients. Methods: This study used a cross-sectional diagnostic test design with the subjects were patients diagnosed with PAD, both outpatients and inpatients at Prof. DR. R.D Kandou Manado. ABI, PWHD and angiography examination were performed on all study subjects. Results: The data show that ABI has a sensitivity of 95.2% and a specificity of 80% in diagnosing PAD patients when compared to angiography as the standard of diagnosis of PAD. PWHD compared to angiography has a sensitivity of 100% and a specificity of 100%. When ABI and PWHD are combined, it has a sensitivity of 100% with a specificity of 80%. The sensitivity and specificity of PWHD compared to angiography based on angiographic location in popliteal artery has a sensitivity of 91.7% and a specificity of 92.6%. PWHD compared with angiography on posterior tibial artery (PTA) has a sensitivity of 81% and a specificity of 88.9%. ABI compared with angiography on dorsalis pedis artery has a sensitivity of 100% and a specificity of 71.4%, with p <0.0001. Conclusion: The high sensitivity and specificity of ABI and PWHD can be used as a diagnostic test tool for PAD patients by general practitioners in first level health facilities.