CT angiography of abdomen and pelvis in critically ill COVID-19 patients: imaging findings and correlation with CT chest score
Harsna V. Vadvala, Alam Shan, Elliot K. Fishman, Rakhee S. Gawande
Abdominal Radiology. Published online, 11 June 2021. https://doi.org/10.1007/s00261-021-03164-y
Dr. Charikleia Triantopoulou, Head of the Radiology Department and Paraskevi Vlachou, Consultant Radiologist ‘Konstantopouleion’ General Hospital of Nea Ionia, Athens Greece.
The COVID-19 disease is a global pandemic, affecting more than 185 countries worldwide. SARS-COV2 is a highly infectious virus, responsible not only for acute respiratory syndrome, but also encompasses a high possibility for vascular and coagulation disorders, the leading factor for high mortality rates.
COVID-19 disease seems to result in a multi system dysfunction (1) with the involvement of several organs as well as vascular involvement. Endothelial injury and inflammation associated with SARS-COV2, mediate reactions which promote vascular complications.
In this retrospective study, the authors intended to focus on the most common vascular abnormalities seen in COVID-19 patients and combine them with the severity of lung disease.
COVID-19 patients admitted to the hospital underwent CTA chest, abdomen and pelvis or CTA abdomen and pelvis studies. Patients should be >18 years old, with diagnosis of COVID-19 infection. Exclusion criteria for this study were examinations performed prior to diagnosis, or examinations performed later than 3 months from initial COVID diagnosis. All studies were reviewed by two independent experienced radiologists.
Firstly, CT chest score was estimated. The five lung lobes were evaluated individually, on a scale from 0 (no involvement- 1 for <5% involvement, 2 for 5-25%, 3 for 26-50%, 4 for 51-75%) to 5 (for more than 75% involvement). The sum of the scores of all five lobes ranges from 0 to 25 (maximal involvement).
Then, analysis of CTA abdomen and pelvis revealed many vascular disorders. Most common were hematomas (46,7%). Second comes active vascular extravasation (24.4%). 8 patients had vascular occlusion and finally artery occlusion was seen in 3 patients. Arterial pseudoaneurysm was even rarer.
After statistical analysis, it was proven that there is strong association between high incidence of vascular disorders and higher CT chest score. Patients with moderate (11-17) to severe (18-25) scores, had had 6,22 to 21 times more possibilities to develop vascular disorders, compared to those with low CT chest score (2).
Additionally, high CT chest score seems to be associated with other types of injury (non-vascular), as abdomen and pelvis CT reveals. Most common sites of involvement are biliary tree, liver, kidneys and GI tract.
In this study, the authors try to summarize all vascular complications in a very helpful and comprehensive way. They also refer to other studies, i.e. Nadkarni et al (3), which emphasizes the benefits of prophylactic anticoagulation therapy, in comparison to those who did not receive any anticoagulation. A total of 46,7% developed a hematoma and 24,4% of patients had emergency active vascular extravasation.
Despite the bleeding propensity, thrombotic complication rate still remains higher as several studies demonstrated (4). Thus, the literature suggests that prophylactic anticoagulation is crucial, for less mortality and less intubation rates, nonetheless underlines the necessity for caution and strict compliance with anticoagulation guidelines in very sick COVID-19 patients.
Similar results were obtained about non-vascular findings. That means patients with higher CT chest score, had more often and more prominent abdominal and pelvis findings, such as cholestasis, hepatitis, acute pancreatitis, bowel ischemia, acute diverticulitis, renal infarcts etc. Therefore, another highlight of this study is the necessity for performing abdominal and pelvis CT, as a routine (5).
In conclusion, this efficient study used a relatively small sample, but it is an adequate cohort for CTA of abdomen and pelvis, proving the hypothesis of the study, that critically ill COVID-19 patients (high scores of CT chest), have significantly higher rates of vascular and non-vascular complications.
References:
- COVID-19- A vascular disease. Hasan K. Siddiqi et al. Trends Cardiovasc Med. 2021 Jan;31(1):1-5
- Vascular comorbidities worsen prognosis of patients with heart failure hospitalized with COVID-19. Jacob Mok et al. Open Heart. 2021 Jun;8(1):e001668. doi:10.1136/openhrt-2021-001668
- Anticoagulation, Bleeding, Mortality, and Pathology in hospitalized patients with COVID-19. Nadkarni et al. J Am Coll Cardiol. 2020;76(16):1815-26
- Thromboembolic risk and anticoagulant therapy in COVID-19 patients: emerging and call for action. Kollias A et al. Br J Haematol. 2020;189(5):846-7.
- Abdominal Imaging Findings in COVID-19: Preliminary Observations. Rajesh Bhayana et al. Radiology. 2020 Oct; Published Online https://doi.org/10.1148/radiol.2020201908
Paraskevi Vlachou MsC, is a young radiologist at ‘Konstantopouleion’ General Hospital of Nea Ionia-Athens, Greece. She is an active ESGAR member, attending regularly annual meetings and workshops. Her main interest is in abdominal and breast radiology. She completed a postgraduate programme at Athens University in Interventional Radiology and in 2016 she won a 3-month ESOR scholarship in Breast Imaging, at Policlinico Agostino Gemelli in Rome.
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