The Impact of COVID-19 on Vascular Surgery Practice: A Systematic Review.

BACKGROUND: COVID-19 is characterized by a pulmonary interstitial compromise which can require intensive care unit (ICU) and mechanical ventilation. Covid patients develop a wide range of pathologies. This study aims to identify the impact of COVID-19 in diseases commonly treated by vascular surgeons. METHODS: Four conditions were selected: venous thromboembolism (VTE), pulmonary embolism (PE), peripheral arterial disease (PAD), and microangiopathy. A systematic review of the literature using PRISMA guidelines was. RESULTS: Out of 1195 papers reviewed for conditions in COVID-19 patients relevant to routine vascular surgery practice, 43 papers were included and analyzed. Venous thrombosis was found to be the most common COVID-19 associated pathology with a cumulative incidence of 25% at 7 days and 48% at 14 days. Additionally, D-dimer levels proved to be a good predictor, even in the early stages of the disease with a sensitivity of 85%, specificity of 88.5% and a negative predictive value of 94.7%. Patients in the ICU demonstrated a significantly higher risk of developing VTE, even when receiving pharmacologic thromboprophylaxis. Although evidence of arterial thrombosis was less common (1% to 16.3%), its consequences were typically more serious, including limb loss and death even in young individuals (OR = 25, 95% CI). Finally, microangiopathy has a wide spectrum of clinical presentations from retinal microangiopathy to other more severe manifestations such as myocardial injury, pulmonary compromise and potential multiple organ dysfunction syndrome. CONCLUSIONS: Although the pathophysiological pathway by which COVID-19 produces thrombosis is not completely clear, the incidence of both arterial and venous thrombosis is increased. D-dimer screening should be done in all COVID-19 patients, as a predictor of thrombotic complications.

CARE-Placental site trophoblastic tumor presenting with thrombotic microangiopathy: A case report.

RATIONALE: Placental site trophoblastic tumor (PSTT) is a rare form of gestational trophoblastic neoplasm (GTN). PATIENT CONCERNS: A 28-year-old Chinese female with initial presentation of thrombotic microangiopathy (TMA) with symptoms of edema of the lower extremities and eyelid, thrombocytopenia and anemia. DIAGNOSES: The primary diagnosis was chronic glomerulonephritis according to the related laboratory tests and clinical symptoms. INTERVENTIONS: A total abdominal hysterectomy with a bilateral salpingectomy was performed. OUTCOMES: The PSTT patient was cured, which contributed to the symptom relief of TMA. LESSONS: This case report aims to elucidate the relationship between TMA and PSTT, so as to achieve timely diagnosis and treatment and reduce misdiagnosis.

Renal pathology in hematopoietic cell transplant recipients: a contemporary biopsy, nephrectomy, and autopsy series.

Renal injury in hematopoietic cell transplant recipients may be related to a combination of factors including chemotherapy, radiation, infection, immunosuppressive agents, ischemia, and graft-versus-host disease, and can involve glomerular, tubulointerstitial, and vascular structures. We reviewed renal pathology from 67 patients at a single institution (2009-2014), including 14 patients with biopsy for clinical dysfunction, 6 patients with surgical kidney resection for other causes, and 47 autopsy patients. Kidney specimens frequently contained multiple histopathologic abnormalities. Thrombotic microangiopathy, membranous nephropathy, minimal change disease, and focal segmental glomerulosclerosis were the most common glomerular findings. Pathologies not previously reported in the hematopoietic cell transplant setting included collapsing glomerulopathy, antiglomerular basement membrane disease, fibrillary glomerulonephritis, and in the case of two surgical resections distinctive cellular segmental glomerular lesions that defied classification. Kidney specimens frequently demonstrated acute tubular injury, interstitial fibrosis, arteriolar hyaline, and arteriosclerosis. Other kidney findings at autopsy included leukemia and amyloid (both recurrent), diabetic nephropathy, bacterial infection, fungal invasion, and silver deposition along glomerular and tubular basement membranes. Also in the autopsy cohort, C4d immunohistochemistry demonstrated unexpected membranous nephropathy in two patients, yet C4d also colocalized with arteriolar hyaline. This retrospective hematopoietic cell transplant cohort illustrates multifaceted renal injury in patients with renal dysfunction, as well as in patients without clinically recognized kidney injury.

Long-term outcome of reusing a kidney allograft retrieved from a living recipient and retransplanted into a second recipient.

This case report shows that the 5-year outcome of a reused kidney from live-kidney allograft recipients because of intractable recurrence of thrombotic microangiopathy was excellent.

Bilateral nephrectomy for the treatment of refractory lupus nephritis with features overlapping with thrombotic microangiopathy resembling thrombotic thrombocytopenia purpura.

We report a patient with a diagnosis of systemic lupus erythematosus who concurrently developed a syndrome of thrombotic microangiopathy that resembled thrombotic thrombocytopenic purpura. The patient underwent plasma exchange and immunosuppressive therapy for months before clinical improvement was finally achieved through bilateral nephrectomy. Ultimately, our patient died of disseminated aspergillosis from prolonged immunosuppression. We believe that recognition of bilateral nephrectomy as a potential treatment earlier in her course would have spared her this unfortunate demise. We hope that this review of current literature will help the reader to consider bilateral nephrectomy in patients with refractory systemic lupus erythematosus with clinical overlap of thrombotic microangiopathy resembling thrombotic thrombocytopenic purpura.

Third-party mesenchymal stromal cell infusion is associated with a decrease in thrombotic microangiopathy symptoms observed post-hematopoietic stem cell transplantation.

TA-TMA is a pathology that occurs after allogenic HSC transplantation with an incidence of 4-13%, and represents one of the most severe vascular damage related with this therapy. We report here the case of a nine-yr-old girl suffering from a severe refractory aplastic anemia who received an unrelated, 9/10 HLA-matched HSC. Soon after transplantation, the patient developed a graft-versus-host disease (GvHD), a TA-TMA, and renal insufficiency. These pathologies remained refractory to the various treatments undertaken and required several hospitalizations in the intensive care unit. On day 106 post-HSC transfusion, after several episodes of intensive care, the patient was infused with mismatched, third-party MSCs. Schizocyte levels rapidly decreased after MSC infusion, and two wk later, most biological parameters returned to normal. Erythrocyte and thrombocyte transfusions were discontinued, and the patient remained stable for 10 wk. Thereafter, TA-TMA symptoms, viral reactivation, pleural and cardiac effusions reappeared and lead to the death of the patient. Our observations suggest that allogenic MSC infusion may decrease the symptoms of TA-TMA, but further investigation is required to determine how and when MSC should be infused to develop a long-lasting protective effect.