Discussion
The surgical management of vascular complications of COVID-19 patients is challenging regarding the critical condition of many COVID-19 patients and the high-risk of aerosolization and related healthcare provider contamination. Two original findings are reported in this technical paper.
First, the occurrence of head and neck vascular complications in ICU patients, which were poorly referenced in the literature. SARS-CoV-2 is known to be associated with endothelial inflammation that weakens the vascular wall.1 In our first reported case, it seems conceivable that the tracheotomy tube could have weaken the cricoarytenoid artery through a friction mechanism. This kind of post-tracheotomy complication was however poorly reported in the literature,3 strengthening the need to monitor patients with severe COVID-19 after the realization of surgical tracheotomy. In the second cases, the vascular lesion was relatively far from the anatomical site of tracheotomies that were performed in front of the third tracheal ring. Thus, we believe that the hemorrhage of the second patient was not associated with the tracheotomy procedure, but it was probably enhanced by the COVID-19 endothelial weaken, the patient comorbidities and the use of preventive anticoagulation therapy.
Second, the rational to perform conservative treatment in COVID-19 patients was based on the critical condition of patients, the high risk of aerosolization2,4 and the related risk of healthcare provider contamination, especially otolaryngologists.5 In this paper, we report two original interventional radiological approaches for the treatment of vascular lesions of the head and neck region. To the best of our knowledge, there is no similar paper in the literature reporting such percutaneous and endovascular approaches in the COVID-19 context. On the one hand, these approaches avoid the risk of aerosolization during the surgery revision where otolaryngologists mobilize the tracheotomy tube. On the other hand, general anesthesia is not required that may be valuable for patients who have comorbidities and critical clinical condition. Notwithstanding the COVID-19 situation, interventional radiological management of bleeding from superior or inferior thyroid arteries was rarely reported3 despite safety, fast realization and adequate post-intervention outcomes of these approaches.6