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Clinical Outcomes of AcuteAortic Thrombi and COVID 19
Jason F Howard1, Qingwen Kawaji1, Darshan Randhawa2, David Blitzer2, Michael Rouse2, Suzanne Kool2, Jason Chin2, Raghuveer Vallabhaneni1, Jason Crowner1
1MedStar Baltimore, Baltimore, MD;2MedStar Baltimore, Rossville, MD

Introduction: The clinical relationship between the COVID-19 virus and thromboembolic events has received considerable attention throughout the pandemic. There has been a rise in aortic thrombi seen anecdotally and in several case reports. The purpose of this case series is to focus on the presentation and outcomes of patients with concomitant aortic thrombi and COVID-19 infection since January 2020.
Methods: We performed a retrospective chart review of multiple hospitals within a large hospital system from 1/1/2020 to 7/1/2021 of patients >18 years of age with concomitant diagnoses of COVID-19 and aortic thrombus. Patients were identified by querying diagnostic codes for: COVID-19 infection and aortic thrombusExclusion criteria were those patients with trauma, malignancy, or non-acute thrombi. Demographics were obtained from the cohort. Main endpoints included mortality and surgical interventions. Secondary endpoints were anticoagulation use, vascular consultation/involvement, and vascular follow up. 
Results: 11 out of 67413 patients (0.02%) met criteria over the 1.5 year time period. Patients had a mean age of 65.5 years, were females 63.6%, and African American 54.5%. Most common presentation was shortness of breath 54.5% and malaise 27.3%. There was a high prevalence of hypertension (81.8%), diabetes (63.6%), coronary artery disease (72.7%), and chronic obstructive pulmonary disease (45.5%).  72.7% of patients were categorized by a body mass index (BMI) of overweight or higher. Thrombi was most prevalent in the ascending aorta 45.5% (Table 1), with 27.3% having multiple locations. Roughly 1/3 of patients (36.4%) presented with aortic occlusion. Overall mortality was 18.2%. Nearly half the patients (45.5%) underwent an intervention (Table 2), of these, 40% required subsequent amputation. Vascular surgery was consulted in 90.9% of cases with an average time to consult of 3.9 days. Vascular surgery follow up was made in 55.6% of surviving patients, and the majority of patients (88.9%) were anticoagulation (62.5% apixaban, 37.5% coumadin).  
Discussion: Although the incidence of aortic thrombi in association with COVID-19 is low, the overall mortality was nearly 20%, with half of the patients necessitating an intervention and over half of those requiring a subsequent amputation. Aortic thrombi are a rare but serious complication of COVID-19 that we should be aware of, as it can have a significant impact on patient outcomes.
Table 1: Thrombi location

PatientThrombi Location Characteristic
1Ascending,Right ICAFree FloatingOcclusive
2Ascending/Descending, Abdominal,R MCAFree FloatingFree FloatingOcclusive
3AscendingFree Floating
4AscendingFree Floating
5Abdominal,B/L SFA/PoplitealFree FloatingOcclusive
7AbdominalNear Occlusive
8Descending,Aortoiliac,B/L PoplitealFree FloatingOcclusiveOcclusive
9AbdominalFree Floating
10AscendingFree Floating

1Cerebral Angiogram, Right ICA ThrombectomyStroke
2Bilateral SFA/Popliteal ThrombectomyRight BKA
3Aortogram and Bilateral CIA StentsDischarged Home
4Aortoiliac, Bilateral Popliteal Thrombectomy and Bilateral FasciotomySepsis, Mortality
5Bilateral CIA Stents, Bilateral FasciotomyDebridement, Right BKA, Left AKA

Table 2: Operative intervention

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