SHM Converge Scientific Abstract ePoster Gallery-Massive Arterial Thrombosis in a Patient With Covid-19 While on Full Dose Anticoagulation

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A 56-year-old woman with hypertension, prior cerebrovascular accident, coronary artery disease, and atrial fibrillation on full-dose apixaban (5 mg twice daily) plus aspirin presented with worsening left arm weakness and was found to have ischemic left upper extremity. CTA of the chest, abdomen, and pelvis showed extensive arterial thrombosis: thrombus in the aortic arch extending into the left subclavian artery with near occlusion, as well as additional thrombi in the infrarenal aorta and above the aortic bifurcation. Laboratory testing revealed elevated D-dimer, CRP, thrombocytosis, and ferritin. She tested positive for COVID-19. Antiphospholipid antibody testing was negative, ruling out APLA syndrome.<br /><br />She underwent emergent vascular surgery, including left brachial artery exploration, angiogram, thrombectomy and repair, and left subclavian artery bypass. Postoperatively, she was treated with intravenous heparin and later transitioned from apixaban to warfarin at discharge. She improved on this regimen.<br /><br />The case highlights COVID-19–associated hypercoagulability, in which venous thromboembolism is more common than arterial thrombosis. Reported mechanisms include endothelial injury, inflammation, elevated fibrinogen, factor VIII, vWF, prothrombotic microparticles, complement-mediated injury, and immobilization. Although arterial events such as stroke, myocardial infarction, limb ischemia, and aortic thrombosis are recognized in COVID-19, massive arterial thrombosis despite therapeutic anticoagulation is extremely rare. Elevated D-dimer has been linked to arterial thrombotic risk in COVID-19.

Asset Subtitle

Nithin G. Thomas

Meta Tag

Author List Meghana Gore, Modupe Idowu, Nithin G. Thomas

Category Clinical Vignettes

Concept COVID-19

Concept Hypercoagulable State

Concept Arterial Thrombosis

Concept Venous Thrombosis

Concept Limb Ischemia

Distinguished Non-Finalist

Presenter Organization Department of Emergency Medicine, McGovern Medical School at UT Health Science Center, Houston

Presenting Author Nithin G. Thomas

Track Adult

Keywords

COVID-19

arterial thrombosis

aortic arch thrombus

left upper extremity ischemia

apixaban failure

warfarin

heparin

subclavian artery bypass

hypercoagulability

elevated D-dimer

COVID-19

Hypercoagulable State

Arterial Thrombosis

Venous Thrombosis

Limb Ischemia