The coronavirus disease 2019 (COVID-19) overwhelmed the healthcare system. Early published 3 reports on the clinical course have been crucial for developing treatment paradigms (1, 2, 3). The 4 identification of a prothrombotic state has been reported and associated with increased mortality 5 rates. Venous thrombotic events have been reported in critically ill COVID-19 patients, 6 predominantly those that are already critically ill (4,5). Arterial events in the form of ischemic 7 strokes and myocardial infarctions have also been reported (1,5,6).. We report four cases of acute 8 arterial large vessel thrombosis, in the absence of severe pulmonary symptoms, generalized 9 sepsis, or severe peripheral vascular disease. Institutional IRB approval and patient consent was 10 obtained for publication of case details and images.
Case #1: Aorto-iliac and Femoral-Popliteal Thrombosis 13 14 A 39-year-old Hispanic male non-smoker with no past medical history, presented to the 15 emergency room with acute lower extremity weakness for six-hours. The patient reported one 16 week of dry cough and fevers. He tested positive for COVID-19. On examination, there was The patient was taken for emergent thrombectomy, where acute thrombus was removed from the 5 popliteal and tibial arteries. The vessels were soft without evidence of arterial occlusive disease.
Distal perfusion was restored intraoperatively and doppler signals were insonated. The patient 7 was extubated after 10 days in the ICU and was subsequently discharged on therapeutic 8 anticoagulation. A hypercoagulable workup was unremarkable, and echocardiogram did not 9 reveal any source of potential embolism. Inflammatory markers were elevated during the acute 10 phase of the infection (table I) . patients. Large vessel arterial thrombosis with cerebrovascular thrombosis and stroke has been 7 reported (10). As with our patients, these thromboses occurred early, without severe pulmonary 8 disease. We found major vessel arterial thrombosis occurred at a rate of 1% or less of patients 9 hospitalized with COVID-12. Only 4 patients were identified out of a 773 hospitalized in our 10 institutions at the time of this report.
The choice of intervention in our cases was guided by the need to limit interventions exposing 13 these patients to stressful procedures, the desire to limit exposure of medical personnel and the 