COVID-19 triggers an inflammatory condition caused by the SARS-Cov-2 virus. Thrombotic events have been commonly described in patients with COVID-19 and they are responsible for a large percentage of deaths seen from this virus. There is no general consensus on how to approach these thrombotic events at this time.1,2 We describe a case of a thrombotic occlusion of the distal superficial femoral (SFA), popliteal artery and all proximal tibials, 2 weeks after the patient was exposed to COVID-19, and later confirmed to have acquired the infection. Patient was able to jog for 2.5 miles and walk an additional 2 miles immediately prior to this event. Treatment was carried on with the Auryon™ laser system (Angiodynamics) with a built in aspiration mechanism. No filter was used and the treatment was guided by intravascular ultrasound (IVUS). Normal flow to the foot was restored with minimal residual narrowing.
A 73-year-old gentleman referred for evaluation of left lower extremity claudication and rest tingling with dependent rubor (Rutherford Becker 4). Patient was very active prior to the symptom’s emergence. He was able to jog about 2.5 miles and walk an extra 2 miles daily with no symptoms. Two weeks prior to the onset of his claudication he developed loss of smell and had intermittent fever. He also noted diffuse muscle aches, diminished appetite, and lost 18 pounds. He had no dyspnea or cough. Patient had been exposed to COVID-19 a few days prior. Since he had no cough or shortness of breath, he was not eligible at the time to have a COVID-19 test. He had no history of diabetes mellitus or hypertension and had a remote history of smoking. Ankle brachial index (ABI) showed a significant reduction on the left at 0.39. The symptom’s onset was abrupt suggestive of a sudden thrombotic event. CT angiogram showed a totally occluded distal left SFA, popliteal artery and proximal tibial vessels (TASC D lesion) and no other obstructive disease in the peripheral vasculature. COVID-19 nasal swab test was ordered again and was allowed given patient need to undergo a peripheral vascular procedure. This was negative initially and remained negative after 48 hours recheck. A nasopharyngeal swab was repeated on admission to the hospital (hospital required) and was positive this time, illustrating the importance of sampling location. The COVID-19 antibody was also later positive.
Patient underwent peripheral angiography and baseline images confirmed the CTA findings (Figure 1A). The lesion was crossed successfully with a CXI (Cook) 0.018” crossing catheter and a 12 gm Approach wire (Cook). The wire was later changed to a Spartacore wire (Abbott). Since we suspected an underlying thrombotic event and there is very little room for an embolic filter protection, we elected to use the Auryon™ laser with aspiration system to treat the lesion. Intravascular ultrasound (IVUS) was initially performed. The Eagle Eye Platinum IVUS catheter (Philips) was used (Figure 2A). The 1.5 laser was initially used and was taken all the way down into the posterior tibialis artery (PT) which also was proximally occluded. The peroneal and anterior tibialis arteries were occluded at their origin. Following this we proceeded with the use of the laser 2.0 (with aspiration) to treat the distal SFA and the popliteal. IVUS sizing of the PT showed a vessel of 3.8 mm on average in diameter. The 4.0 mm Lutonix (Bard/BD) drug coated balloon (DCB) was used to treat the PT into the tibioperoneal trunk. This was followed by Lutonix treatment to the distal left SFA and popliteal. DCB were used for a total of 3 minutes’ inflation each. Brisk flow was established all the way to the foot (Figure 1). No complications or angiographic dissections were noted and less than 100 cc of blood was aspirated. Stenting was not required.
This case illustrates the occurrence of thrombotic events and the occurrence of critical limb ischemia with the COVID-19 infection. Although a cause-effect could not be directly established between the virus infection and the occurrence of the thrombotic event, the timing with a patient confirmed to be positive for the infection and the sudden occurrence of symptoms in a highly active patient with no other vascular disease suggest a strong association between the SARS-Cov-2 virus and the occurrence of the thrombus. This has been now widely described in several publications where COVID-19 was described to cause strokes, pulmonary embolization, heart attacks and vascular thrombosis. The ideal treatment is unclear and traditional lysis and anticoagulation have been used. More data are clearly needed to demonstrate the ideal anticoagulation regimen in these patients. Furthermore, mechanical aspiration systems are likely to be effective but intraprocedural success and follow-up anticoagulation remain unclear. In this case we elected to use the Auryon™ laser system.
The Auryon™ laser is a newly approved laser with a built in aspiration system for the 2.0 and 2.35 catheters. In the IDE study3, no distal embolization was reported despite the use of only 2 filters. Auryon™ was approved for all lesion morphologies by the FDA. With the ability of the laser to vaporize plaque and thrombus, the reduction of thrombus burden is likely to be significant. In this case, the laser was used in a subacute thrombotic lesion in a patient with COVID-19 recent infection and was very effective in restoring normal flow to the foot with no angiographic residual stenosis and no distal embolization despite no use of an embolic filter. Unfractionated heparin was used during the procedure and patient was discharged home on clopidogrel, aspirin (both for at least 6 months) and rivaroxaban 20 mg po daily (for 1 month). Although the effectiveness of this regimen is not clear, the combination of antiplatelet drugs and a short course of an antifibrin drug seem to make sense in a patient with recent thrombotic occlusion and ongoing inflammatory etiology. IVUS has clearly shown that not all thrombus is resolved and keeping the patient on an oral anticoagulant after discharge may reduce the risk of recurrent thrombotic occlusions.
We conclude that the Auryon™ laser system is effective and safe in treating thrombotic lower extremity arterial occlusions in COVID-19 patients. The combination of laser vaporizing thrombus and the aspiration system seems to reduce the thrombus burden and increase the chance of procedural success. More data are needed to confirm these findings.
Key words: Laser atherectomy, distal embolization, COVID-19, thrombus, aspiration
The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr. Shammas receives research and educational grants and is a consultant to Angiodynamics and is on the speaker bureau of Janssen.
Address for correspondence:
Nicolas W. Shammas, MD, MS, FACC
Research Director, Midwest Cardiovascular Research Foundation, Davenport, IA
1. Barnes GD, Burnett A, Allen A, et al. Thromboembolism and anticoagulant therapy during the COVID-19 pandemic: interim clinical guidance from the anticoagulation forum. J Thromb Thrombolysis. 2020;50(1):72-81.
2. Bikdeli B, Madhavan MV, Jimenez D, et al. COVID-19 and thrombotic or thromboembolic disease: Implications for prevention, antithrombotic therapy, and follow-up. J Am Coll Cardiol. 2020;75(23):2950-2973.
3. Shammas NW, Chandra P, Brodmann M, et al. Acute and 30-day safety and effectiveness evaluation of Eximo Medical's B-Laser™, a novel atherectomy device, in subjects affected with infrainguinal peripheral arterial disease: Results of the EX-PAD-03 trial. Cardiovasc Revasc Med. 2020;21(1):86-92.