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Radiologic evolution of pulmonary arterial thrombosis associated with SARS-CoV-2 pneumonia

2022; Hogrefe Verlag; Volume: 51; Issue: 4 Linguagem: Inglês

10.1024/0301-1526/a001015

1664-2872

Francesca Giacomazzi, Daniela Mazzaccaro, Simone Schiaffino, Matteo Giannetta, Anastasia Esseridou, Andrea Cozzi, Giovanni Nano, Paolo Righini, Giovanni Di Leo, G. Serino, Francesco Sardanelli,

Long-Term Effects of COVID-19

Free AccessRadiologic evolution of pulmonary arterial thrombosis associated with SARS-CoV-2 pneumoniaFrancesca Giacomazzi, Daniela Mazzaccaro, Simone Schiaffino, Matteo Giannetta, Anastasia Esseridou, Andrea Cozzi, Giovanni Nano, Paolo Righini, Giovanni Di Leo, Giorgio Serino, and Francesco SardanelliFrancesca Giacomazzi Cardiovascular Department, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy Search for more papers by this author, Daniela MazzaccaroDaniela Mazzaccaro, Operative Unit of Vascular Surgery, IRCCS Policlinico San Donato, Piazza Malan 1, 20097 San Donato Milanese, Italydanymazzak83@libero.ithttps://orcid.org/0000-0002-7414-642X Operative Unit of Vascular Surgery, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy Search for more papers by this author, Simone Schiaffino Unit of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy Search for more papers by this author, Matteo Giannetta Operative Unit of Vascular Surgery, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy Search for more papers by this author, Anastasia Esseridou Unit of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy Search for more papers by this author, Andrea Cozzi Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy Search for more papers by this author, Giovanni Nano Operative Unit of Vascular Surgery, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy Search for more papers by this author, Paolo Righini Cardiovascular Department, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy Search for more papers by this author, Giovanni Di Leohttps://orcid.org/0000-0003-0954-2634 Unit of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy Search for more papers by this author, Giorgio Serino Cardiovascular Department, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy Search for more papers by this author, and Francesco Sardanelli Unit of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy Search for more papers by this authorPublished Online:July 05, 2022https://doi.org/10.1024/0301-1526/a001015PDF ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinkedInReddit SectionsMoreDear Editor,Pulmonary artery thrombosis in patients with COronariVIrus Disease 19 (COVID-19) pneumonia is a relatively common finding [1], secondary to the combination of known thrombotic risk factors (inflammation, hypoxia and immobilization) and COVID-19-associated coagulopathy [2]. Proper therapy and follow-up are mandatory.Although the international societies recently provided guidance on treatment of thromboembolic disease in COVID-19 patients [3], few data are available concerning the radiologic evolution and the outcomes after treatment of pulmonary thrombosis (PT). Furthermore, PT in the context of COVID-19 has a different pathogenesis if compared to non-COVID-19 cases [2], consequently with possible different therapeutic responses to fibrinolysis and anticoagulation treatment.We retrospectively analyzed the radiologic data of 20 patients who had PT during the in-hospital stay for COVID-19 pneumonia, and who were treated with full anticoagulation therapy with direct oral anticoagulants (DOACs) for three months. Aim of analysis was to assess the rate of pulmonary artery recanalization after 3 months of treatment. As a secondary outcome, we evaluated the radiologic evolution of COVID-19 pneumonia. The Ethics Committee approved this study (168/int/2020).In our experience, a total of 650 patients were hospitalized in a non-intensive care unit ward from 18/03/2020 to 31/12/2020 for COVID-19 pneumonia. Among them, 184 had performed a computed tomographic pulmonary angiography (CTPA) and 28 of them (15.2%) were diagnosed to have PT and were treated with DOACs. In particular, the diagnosis of subsegmental PT was performed according to the recent Delphi consensus [4]. Venous duplex scan of the lower limbs, which was performed in all patients who had PT, was negative in all cases. Of these patients, we included in the study only those who had performed a complete assessment at 3 months with CTPA with ≤ 1 mm slices.Patients’ median age was 69 years (range 64.8–75 years) and there were 6 females (30%). Nine of them (45%) had required non-invasive ventilation with continuous positive airway pressure (either mask or helmet) for worsening respiratory function.Baseline PCTA was performed after a median of 3 days since hospital admission (range 2.9–4 days). Pulmonary thrombosis involved the main trunk in one patient (5%); in the remaining 19 cases, thrombosis was localized at lobar artery and subsegmental arteries in 5 cases each (25%) and at segmental arteries in 9 cases (45%). Ground glass opacity was found in all except one patient at baseline, while pulmonary consolidation in 16 (80%). Two patients (10%) had also atelectasis, 8 (40%) had fibrosis.After 3 months with DOACs, the follow-up CTPA showed total recanalization of occluded arteries in all cases. Ground glass opacity was still present in 8/20 patients (40%), while pulmonary consolidation had completely disappeared in 12/16 patient (75%). However, pulmonary fibrosis had resolved in three cases only. During anticoagulation treatment, neither thrombotic nor hemorrhagic complications were recorded. None of the patients died.There is no consensus about anticoagulation for patient with subsegmental PT. However, a recent trial showed a higher-than-expected rate of recurrent venous thromboembolism in a cohort of patients who had subsegmental pulmonary embolism without deep venous thrombosis and did not receive anticoagulation, if compared to patients who received anticoagulation [5].In our experience, three months of treatment with DOACs were enough to achieve a radiological resolution of the arterial in situ thrombosis in this subgroup of patients, without any hemorrhagic harm nor thrombotic recurrence.Of course, the small sample size of our cohort, as well as the retrospective nature of the study, prevent from the generalization of the observed results. Therefore, further studies are needed to better understand the optimal treatment of PT in COVID-19 patients.References1 Mazzaccaro D, Giacomazzi F, Giannetta M, Varriale A, Scaramuzzo R, Modafferi A, et al. Non-overt coagulopathy in non-ICU patients with mild to moderate COVID-19 pneumonia. J Clin Med. 2020;9(6):1781. First citation in articleCrossref, Google Scholar2 Terpos E, Ntanasis-Stathopoulos I, Elalamy I, Kastritis E, Sergentanis TN, Politou M, et al. Hematological findings and complications of COVID-19. Am J Hematol. 2020;95(7):834–47. First citation in articleCrossref Medline, Google Scholar3 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. JACC state-of-the-art review. J Am Coll Cardiol. 2020;75(23):2950–73. First citation in articleCrossref Medline, Google Scholar4 Den Exter PL, Kroft LJM, Gonsalves C, Le Gal G, Schaefer-Prokop CM, Carrier M, et al. Establishing diagnostic criteria and treatment of subsegmental pulmonary embolism: A Delphi analysis of experts. Res Pract Thromb Haemost. 2020;4(8):1251–61. First citation in articleCrossref Medline, Google Scholar5 Le Gal G, Kovacs MJ, Bertoletti L, Couturaud F, Dennie C, Hirsch AM, et al. Risk for recurrent venous thromboembolism in patients with subsegmental pulmonary embolism managed without anticoagulation: A multicenter prospective cohort study. Ann Intern Med. 2022;175(1):29–35. First citation in articleCrossref Medline, Google ScholarFiguresReferencesRelatedDetails Volume 51Issue 4July 2022ISSN: 0301-1526eISSN: 1664-2872 ReceivedMarch 18, 2022AcceptedMay 16, 2022 InformationVasa (2022), 51, pp. 263-264 https://doi.org/10.1024/0301-1526/a001015.© 2022Hogrefe AGConflict of interestNone.AuthorshipFG: study design, data collection, data interpretation, manuscript preparation, critical revision. DM: study design, data collection, statistical analysis, data interpretation, manuscript preparation, critical revision. SS: data collection, manuscript preparation, critical revision. AE: data collection, data interpretation, critical revision. AC: data collection, critical revision. GN: data collection, data interpretation, critical revision. GDL: data collection, statistical analysis, critical revision. GS: data interpretation, critical revision. FS: study design, data interpretation, critical revision.PDF download Funding None