Symptomatic Extracranial Carotid Disease in COVID-19 Patients Is Related to Thrombus Formation

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Conference Proceeding

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Journal of Vascular Surgery


Background: Coronavirus disease-2019 (COVID-19) has been associated with an acquired hypercoagulable condition. This study was undertaken to review the clinical manifestations of COVID-related symptomatic extracranial carotid artery disease (ECCAD) and compare the carotid plaque composition of symptomatic COVID patients to non-COVID symptomatic patients with ECCAD.

Methods: All patients with neurologic manifestations attributed to ECCAD who had clinical diagnosis of COVID-19 were reviewed. The clinical presentation, outcome, and carotid plaque characteristics of all patients were reviewed, and compared to symptomatic ECCAD patients prior to the COVID era (Table). Plaque composition was determined by analysis of calcium volume (mm3) within the carotid lesion with computed tomography angiography (CTA) using VitreaCore (version 6.7.6001.1) with manual outlining of calcium within the carotid lesions.

Results: Between the period of March 28 and April 12, 2020, seven patients with COVID-19 were admitted with cerebrovascular manifestations (all ischemic strokes) related to carotid bifurcation lesions. Five patients were documented to have COVID-19 by nasal polymerase chain reaction, and two were clinically diagnosed. Two patients had significant clot in the contralateral carotid (Fig). In sic of the COVID patients (86%), their presenting symptom was the stroke, whereas one patient developed a stroke 24 hours after being admitted with respiratory symptoms. Three patients underwent procedural intervention: one with an open carotid thromboendarterectomy and two with macrovascular distal embolization, underwent percutaneous mechanical thrombectomy. The remaining four patients were treated with anticoagulation alone. Seven consecutive patients with strokes secondary to ECCAD were selected from the pre-COVID era for comparison (Fig). The calcium plaque volume was significantly lower in the COVID patients compared to non-COVID patients, 84 mm3 (mean) compared to 401 mm3 (mean) (P =.02).

Conclusions: In COVID patients presenting with strokes and concomitant ipsilateral extracranial carotid lesions, there is more thrombus burden and less calcification than in typical carotid atherosclerotic lesions. This analysis reinforces that the underlying pathology of this COVID-related clinical entity is one of hypercoagulability.





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