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First, do no harm: bilateral radial artery occlusion in a COVID-19 patient
Anne Bouwhuis1,2, Patrick Schober2, Leo M A Heunks1
1Department of Intensive Care, Amsterdam University Medical Center (Location VUMC), Amsterdam, Netherlands.
Insights
This case report highlights bilateral radial artery thrombosis, a rare complication in COVID-19 patients. Early detection of compromised hand perfusion is crucial to prevent ischemia during medical interventions.
Area of Science:
- Vascular Medicine
- Infectious Diseases
- Critical Care Medicine
Background:
- COVID-19 is associated with an increased risk of thrombotic events.
- Arterial complications, though less common than venous, warrant attention.
- This case focuses on a specific, under-recognized arterial complication.
Observation:
- A 49-year-old male with COVID-19 developed bilateral radial artery occlusion.
- The patient had risk factors including obesity, smoking, and diabetes, but no prior atherosclerotic disease.
- Diagnostic imaging and functional tests confirmed occlusion and assessed collateral circulation.
Findings:
- Doppler sonography revealed occlusion of both radial arteries, with flow preserved in ulnar arteries.
- Functional tests demonstrated dependence of hand perfusion on ulnar artery patency.
- Bilateral radial artery thrombosis occurred despite therapeutic anticoagulation.
Implications:
- COVID-19 patients may be at higher risk for arterial thrombosis.
- Meticulous assessment of collateral hand perfusion is recommended before radial or ulnar artery interventions.
- Failure to assess collateral flow could lead to hand ischemia.
Objective:
Objective of this case report is to draw attention to a less known thrombotic complication associated with COVID-19, i.e., thrombosis of both radial arteries, with possible (long-term) consequences.
The Case:
In our COVID-19 ICU a 49-year-old male patient was admitted, with past medical history of obesity, smoking and diabetes, but no reported atherosclerotic complications. The patient had been admitted with severe hypoxemia and multiple pulmonary emboli were CT-confirmed. ICU-treatment included mechanical ventilation and therapeutic anticoagulation. Preparing the insertion of a new radial artery catheter for invasive blood pressure measurement and blood sampling, we detected that both radial arteries were non-pulsating and occluded: (a) Sonography showed the typical anatomical localization of both radial and ulnar arteries. However, Doppler-derived flow-signals could only be obtained from the ulnar arteries. (b) To test collateral arterial supply of the hand, a pulse-oximeter was placed on the index finger. Thereafter, the ulnar artery at the wrist was compressed. This compression caused an immediate loss of the finger's pulse-oximetry perfusion signal. The effect was reversible upon release of the ulnar artery. (c) To test for collateral perfusion undetectable by pulse-oximetry, we measured regional oxygen saturation (rSO2) of the thenar muscle by near-infrared spectroscopy (NIRS). Confirming our findings above, ulnar arterial compression demonstrated that thenar rSO2 was dependent on ulnar artery flow. The described development of bilateral radial artery occlusion in a relatively young and therapeutically anticoagulated patient with no history of atherosclerosis was unexpected.
Conclusions:
Since COVID-19 patients are at increased risk for arterial occlusion, it appears advisable to meticulously check for adequacy of collateral (hand-) perfusion, avoiding the harm of hand ischemia if interventions (e.g., catheterizations) at the radial or ulnar artery are intended.
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