CASE 2
A 70-year-old male patient (PADUA index: 5, Caprini index: 7) was
confirmed as having COVID-19 disease when he received a routine
preoperative pulmonary CT scan due to arterial and venous thrombosis in
the right extremity. After 25 days of chronic ischemia, there was dry
gangrene of his right thigh (Fig. 2A ). On admission to
hospital, physical examination showed that his right lower limb appeared
swollen and tender; displayed cyanotic change with a diminished dorsalis
pedis pulse. Color US detection determined that he was suffering from a
right iliac arterial and venous embolism. A series of other poorly
prognostic symptoms, such as left toe ischemia (Fig. 2B ) and
left lower extremity inter-muscular venous thrombosis were also found.
His abdominal aorta and left iliac arteries remained unobstructed. His
only past medical history of note was surgery for lung cancer four years
previously.
Initial laboratory tests (Table 2 ) showed a high CRP (65.85
mg/L), white blood cell (9.83 G/L), neutrophil count (7.49 G/L), alanine
transaminase (ALT) (127 U/L), aspartate transaminase (AST) (119 U/L)
levels, D-dimer (6.55 ug/mL) and fibrinogen (FIB) (5.6g/L). Creatine
kinase-MB (CKMB) and hsTNI levels were normal. His oxygen saturation
(SPO2) was 89%-91% for room air and 96% on high-flow nasal cannula
oxygen therapy (HFNC). He was unable to undergo revascularisation
surgery to salvage the right lower limb. He was scheduled for right
thigh amputation surgery following IVCF implantation (Figs.
2C-2E ). At day 1, he received anticoagulation (enoxaparin, 4000U, s.c),
an antibiotic and supportive therapies.
At day 2, this patient was scheduled for implantation of a retrievable
Cook Celect IVCF (William Cook, Europe) for preventing acute pulmonary
embolism (PE) during the amputation surgery. The intervention was
performed with bedside US on the isolation ward. This confirmed patency
of the inferior vena cava, left iliac vein, and femoral vein. It also
assured that percutaneous US guided IVCF implantation is feasible
(Fig. 2C ). After local anesthesia and successful Seldinger
puncture of the left femoral vein, the filter sheath was visually
inserted into the left femoral vein through one 6Fguide sheath. Next, we
injected 10 mL diluted SonoVue US contrast agent (Bracco, Milan, Italy)
through the filter sheath to adjust the catheter tip location. The tip
of the filter sheath was anchored 1cm below the right renal vein
(Fig. 2D ). The filter was delivered into the catheter and
deployed according to the manufacturer’s recommendations (Fig.
2E ). IVCF was deployed successfully.
The patient was transferred to a disinfected theatre and proceeded with
right thigh amputation surgery. Post-operatively, he was transferred to
the isolated intensive care unit (ICU). Severe bilateral pneumonia was
confirmed on a bedside chest X-ray on day 3 (Fig. 2F ).
The IVCF position remained unchanged (Fig. 2F ). His D-dimer had
progressively decreased from the initial value of 6.55 μg/mL to 2.85
μg/mL at day 7 after continuous anticoagulation therapy (enoxaparin,
4000U, s.c, q12 h). At day 9, he suffered an acute cardiac event with
elevated hsTNI (10025.40 ng/L). He was treated medically for acute
coronary syndrome. Supportive management was also optimised. A chest
X-ray again confirmed severe bilateral pneumonia with no shit in the
IVCF. At day 10, the creatine kinase-MB (CKMB) (262.70 ng/mL) and hsTNI
(>50000.00 ng/L) levels kept increasing despite aggressive
medical therapy. The patient eventually passed away on day 11
(Table 2 ).