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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 9  |  Issue : 4  |  Page : 100-102

Left Subclavian Arterial Thrombosis Presenting as Acute Limb Ischemia in a Coronavirus Disease 2019 Patient – An Extreme Rarity


Department of Cardiology, Rajarshree Chhatrapati Shahu Maharaj Government Medical College and CPR Hospital, Kolhapur, Maharashtra, India

Date of Submission08-Jul-2020
Date of Decision25-Sep-2020
Date of Acceptance06-Oct-2020
Date of Web Publication24-Dec-2020

Correspondence Address:
Dr. Akshay Ashok Bafna
Rajarshree Chhatrapati Shahu Maharaj Government Medical College and CPR Hospital, Dasara Chowk, Kolhapur - 416 013, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/rcm.rcm_24_20

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  Abstract 


The peak of the coronavirus disease 2019 (COVID-19) crisis has exposed a substantial number of patients presenting with manifestations of venous and arterial thrombosis. Here, described is an extremely rare case of subclavian arterial thrombosis in a COVID-19 patient. Moreover, the patient presented with normal D-dimer, antinuclear antibody, fibrinogen, and serum ferritin levels, prothrombin time and platelet count. To the best of our knowledge, this is the first such case reported till date.

Keywords: Coagulation, coronavirus disease 2019, D-dimer, limb ischemia, subclavian artery, thrombosis


How to cite this article:
Bafna AA, Gajbiye M, Deore K, Shah S, Bafna V. Left Subclavian Arterial Thrombosis Presenting as Acute Limb Ischemia in a Coronavirus Disease 2019 Patient – An Extreme Rarity. Res Cardiovasc Med 2020;9:100-2

How to cite this URL:
Bafna AA, Gajbiye M, Deore K, Shah S, Bafna V. Left Subclavian Arterial Thrombosis Presenting as Acute Limb Ischemia in a Coronavirus Disease 2019 Patient – An Extreme Rarity. Res Cardiovasc Med [serial online] 2020 [cited 2021 May 7];9:100-2. Available from: https://www.rcvmonline.com/text.asp?2020/9/4/100/304780




  Introduction Top


Coronavirus disease 2019 (COVID-19) is a viral respiratory disease; therefore, it has been primarily treated as a severe respiratory infection worldwide. However, the peak of the pandemic has exposed several cases marked by manifestations of venous and arterial thrombosis. A substantial number of patients have displayed coagulation abnormalities mimicking other systemic coagulopathies associated with severe infections, often disguised as venous and arterial thromboembolic complications.[1]


  Case Report Top


A 52-year-old male with no comorbidities presented to our COVID-19 treatment facility with a dry cough and sore throat on admission. National Early Warning Score was 0 on admission. The patient was COVID-19 positive as detected by reverse transcription-polymerase chain reaction. He was prescribed azithromycin 500 mg once daily. Laboratory investigations revealed negative D-dimer levels of <200 ng/ml, negative antinuclear antibody levels, fibrinogen levels of 210 mg/dL, serum ferritin levels of 189 ng/ml, prothrombin time (PT) of 12.8 s, hemoglobin level of 12.7 g/dL, and normal platelet count. On the 7th day of admission, he developed sudden onset of left upper limb claudication, absent pulsation of the axillary, brachial, and radial arteries of the left arm, and pale middle and index fingers. However, no cyanosis was observed. Electrocardiography showed sinus rhythm, normal PR interval, QRSd with QTc of 0.40 s with no evidence of chamber hypertrophy or dilation. Two-dimensional echocardiography was unremarkable. Chest X-ray confirmed right lower lobe pneumonia [Figure 1]a. Urgent computed tomography (CT) angiography of the aortic arch and left arm revealed a large thrombus of 8 cm extending from the origin of the left subclavian artery to the axillary artery [Figure 2]a and [Figure 2]b. Financial constraints of the patient and lack of medical insurance ruled out surgery and endovascular treatment. Furthermore, embolectomy was not feasible due to the proximity of the thrombus to the vertebrae. Thus, in view of the onset of acute limb ischemia within 6 h, it was elected to thrombolyse the patient with 500,000 units of intravenous bolus of streptokinase tapered to 100,000 units/h as a continuous infusion for 24 h after ruling out contraindications for the same. The patient also received aspirin 300 mg, clopidogrel 300 mg, and atorvastatin 80 mg orally.
Figure 1: High-resolution computed tomography showing: (a) Right lower lobe ground glass opacities with septal thickening on admission and (b) Significant clearing of opacities at discharge

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Figure 2: Computed tomography showing: (a and b) Three-dimensional constructed volume rendered technique images of long segment complete acute thrombotic occlusion of the subclavian and axillary arteries pre thrombolysis

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In view of clinical improvement in the form of significant pain relief and return of brisk pulses at the left wrist for more than 24 h, CT angiography of the left subclavian artery was repeated after 24 h which demonstrated almost complete (80%) resolution of the thrombus [Figure 3] with thrombolysis in myocardial infarction (TIMI) III distal flow in the radial artery and TIMI II flow in the distal ulna artery. Administration of low-molecular heparin 60 mg twice daily for 7 days 6 h after extended thrombolysis was initiated, and dual antiplatelet and statin therapy were continued as prescribed earlier. The patient did not experience any bleeding complications during the course of his treatment. Red color of the hand was observed post thrombolysis. After the 7th day, pneumonia was resolved [Figure 1]b. Furthermore, CT angiography confirmed the complete recanalization of subclavian, axillary, radial, and ulna arteries without residual plaque or thrombus [Figure 4]a and [Figure 4]b. After the 14th day, the nasal swab for COVID-19 was repeated, which was negative. The patient was discharged as per the Indian Council of Medical Research Protocol for COVID 19 management. Postdischarge, the patient was prescribed 3 mg warfarin once daily to maintain PT and international normalized ratio in the range 2.0–2.5.
Figure 3: Computed tomography of the left upper arm showing almost complete (80%) recanalization of subclavian and axillary arteries 2 days post thrombolysis

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Figure 4: Computed tomography showing: (a and b) Three-dimensional constructed volume rendered technique images of complete recanalization of subclavian, axillary, radial and ulna arteries without residual plaque or thrombus 7 days postthrombolysis

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  Discussion Top


COVID-19 may predispose patients to thrombotic disease, both in the venous and arterial circulations due to a spectrum of misleading complications such as excessive inflammation, platelet activation, coagulopathy, endothelial dysfunction, and stasis. Several justifications have been set forth to explain the association between COVID-19 and thrombotic disease. First, the direct effects of COVID-19 or indirect effects of the infection, such as critical condition and hypoxia, may predispose patients to thrombotic events. Second, investigational therapies for treating COVID-19 may display adverse drug-drug interactions with antiplatelet agents and anticoagulants.[2] Third, viruses are able to activate the coagulation system, as seen in human immunodeficiency virus, Dengue virus, and Ebola virus.[3],[4] Finally, inaccessibility or unavailability of resources along with social distancing norms may unfavorably affect the care of COVID-19-negative patients presenting with thrombotic events. The most fitting example is the widespread notion that antithrombotic agents confer increased risk for contracting COVID-19. This may, unfortunately, cause several such patients to abandon their anticoagulant or antiplatelet regimen.

The most distinctive hematological finding in COVID-19 patients with coagulopathy is increased D-dimer levels, a modest decrease in platelet count, and prolonged thrombin time.[1] Normal levels of all the aforementioned hematological parameters highlight the rarity of the present case. Nonetheless, regardless of hypercoagulable state, D-dimer level, or fibrinogen level, thrombotic events in COVID-19 patients pose a significant risk, especially to patients in critical condition.

Venous thrombosis in the lower limbs has been described by several investigators during the pandemic. Yet, there is a dearth of evidence describing arterial thrombosis in the upper limbs. Perini et al.[5] in a recent publication in the Lancet recall treating four COVID-19 patients presenting with acute limb ischemia. Interestingly and similar to the present case, none of the patients had atherosclerosis or preexisting blood clotting disorders. One of these patients was a 37-year-old male with thrombosis at the level of the humeral artery bifurcation. After 2 days of unfractionated heparin administration, the acute limb ischemia resolved. However, to the best of our knowledge, the present case is the first-ever case of subclavian artery thrombosis observed in a COVID-19-positive patient with normal D-dimers during this global pandemic. The patient was successfully managed conservatively with systemic thrombolysis. The association between large-vessel thrombus in COVID-19 patients requires further investigations.


  Conclusion Top


COVID-19 is more than a severe respiratory infection. It displays propensity to affect the vasculature of the lungs and multiple other organs. The subsequent acute life-threatening events and increased thrombotic risk necessitate adequate treatment with anticoagulants based on laboratory investigations along with monitoring with appropriate imaging modalities.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Levi M, Thachil J, Iba T, Levy JH. Coagulation abnormalities and thrombosis in patients with COVID-19. Lancet Haematol 2020;7:e438-40.  Back to cited text no. 1
    
2.
Bikdeli B, Madhavan MV, Jimenez D, Chuich T, Dreyfus I, Driggin E, et al. COVID-19 and thrombotic or thromboembolic disease: Implications for prevention, antithrombotic therapy, and follow-up. J Am Coll of Cardiol 2020;75:2950-73.  Back to cited text no. 2
    
3.
Antoniak S, Mackman N. Multiple roles of the coagulation protease cascade during virus infection. Blood 2014;123:2605-13.  Back to cited text no. 3
    
4.
Antoniak S. The coagulation system in host defense. Res Pract Thromb Haemost 2018;2:549-57.  Back to cited text no. 4
    
5.
Perini P, Nabulsi B, Massoni CB, Azzarone M, Freyrie A. Acute limb ischaemia in two young, non-atherosclerotic patients with COVID-19. Lancet 2020;395:1546.  Back to cited text no. 5
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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