key: cord-0686582-apjwzput
authors: Bannazadeh, Mohsen; Tassiopoulos, Apostolos; Koullias, George
title: Acute superior mesenteric artery thrombosis seven days after discharge for novel coronavirus pneumonia (NCP)
date: 2021-02-19
journal: J Vasc Surg Cases Innov Tech
DOI: 10.1016/j.jvscit.2020.12.002
sha: 861f0058085d5666ee20f7ec80ba567b5fdbe116
doc_id: 686582
cord_uid: apjwzput

Since the emergence of novel coronavirus pneumonia (NCP), a number of reports have pointed out an increased coagulation activity in these patients mostly during acute phase of the disease. We are reporting a case of acute superior mesenteric thrombosis in a 55-year-old male with NCP one week after hospital discharge. He returned to the emergency department 7 days later with severe acute abdominal pain and found to have superior mesenteric artery thrombosis. He subsequently underwent emergent exploratory laparotomy, SMA thrombectomy and bowel resection. Acute arterial thrombosis may occur in post hospitalization period in patients with NPC. Since the emergence of novel coronavirus pneumonia (NCP) in December 2019, a number of reports have suggested that a large percentage of patients with novel coronavirus (COVID-19) infection , particularly those that become critically ill, develop a pro-thrombotic state which places them at a significantly increased risk of thrombosis especially during the acute phase that often requires intensive care unit stay with severe acute respiratory distress syndrome (ARDS). 1, 2, 3 Interestingly, a wide range of increase in D-dimer levels has also been documented in hospitalized COVID-19 patients and there are early reports linking higher D-dimer levels to worse outcomes.(4) Based on these reports, most centers employ thrombosis-prevention strategies ranging from prophylactic regimens to full anticoagulation during NCP hospitalization with improved outcomes.(5) The optimal potency and duration of anti-thrombotic management is not clear. In addition, there is little evidence on when the increased coagulation activity returns to normal levels after onset of symptoms. We report a case of acute mesenteric ischemia due to superior mesenteric artery thrombosis in a 55-year-old male patient with NCP one week after hospital discharge. The patient consent to publish the case report was obtained according to our institutional guidelines.

Since the emergence of novel coronavirus pneumonia (NCP) in December 2019, a 1 number of reports have suggested that a large percentage of patients with novel coronavirus 2 (COVID-19) infection , particularly those that become critically ill, develop a pro-thrombotic 3 state which places them at a significantly increased risk of thrombosis especially during the 4 acute phase that often requires intensive care unit stay with severe acute respiratory 5 distress syndrome (ARDS). [1] [2] [3] Interestingly, a wide range of increase in D-dimer levels has 6 also been documented in hospitalized COVID-19 patients and there are early reports linking 7 higher D-dimer levels to worse outcomes. 4 Based on these reports, most centers employ 8 thrombosis-prevention strategies ranging from prophylactic regimens to full 9 anticoagulation during NCP hospitalization with improved outcomes. 5 The optimal 10 potency and duration of anti-thrombotic management is not clear. In addition, there is 11 little evidence on when the increased coagulation activity returns to normal levels after 12 onset of symptoms. We report a case of acute mesenteric ischemia due to superior 13 mesenteric artery thrombosis in a 55-year-old male patient with NCP one week after 14 hospital discharge. The patient consent to publish the case report was obtained according 15 to our institutional guidelines. 16 17 Report 19 20 A 55-year-old African American male presented to the emergency department (ED) with 21 complaints of non-productive cough, fatigue, myalgia, nausea, diarrhea and abdominal 22 pain for 4 days. His past medical history was significant for hypertension and Grave's 23 disease. Medication history included atenolol 100mg daily and methimazole10 mg daily. 1

The patient did not have a history of smoking or illicit drug abuse. He is a construction 2 worker in the New York City area. On physical examination he had mild hypoxia and 3 fever (87% on room air and 101 F). Laboratory tests revealed hyponatremia, 4 hypokalemia, and elevated aspartate aminotransferase (AST) (table 1). Chest X-Ray 5 showed right basilar infiltrates. Influenza A/B was negative and SARS-CORONAVIRUS-6 2 RNA test was positive. He was admitted and started on our hospital COVID therapy 7 regimen including oral Azithromycin 500 mg daily and Hydroxychloroquine 400 mg 8 daily for 5 days. During this time, he received prophylactic anticoagulation with heparin 9 5000 unit subcutaneously daily twice per day in the hospital. 10

Computed tomography (CT) scan with intravenous and oral contrast showed bilateral 11 lower lobe, right middle lobe and lingula groundglass opacification with distribution 12 suggestive of COVID pneumonitis. Abdomen and pelvis were unremarkable with no 13 evidence of mesenteric vessel disease ( Figure 1 ). After treatment initiation, the patient's 14 oxygenation and nausea improved, and he was discharged home after 5 days of 15 hospitalization with 5-day course of levofloxacin 500 mg orally. 16

The patient returned to the ED 7 days after discharge complaining of acute onset of 18 severe abdominal pain. On physical exam he was tachycardic but did not have hypoxia or 19 fever. The abdomen was tender with guarding. Lab results are summarized in table 1. 20

Lactic acid was 6.2 and D-Dimer was at 2400. CT scan of chest, abdomen,and pelvis with 21 intravenous contrast showed interval development of a 1.6 cm long low density thrombus 22

in the proximal superior mesenteric artery (SMA) causing a high grade luminal stenosis 23 J o u r n a l P r e -p r o o f ( Figure 1 ). Electrocardiogram (ECG) showed sinus rhythm with no evidence of 1 myocardial ischemia. The patient transthoracic echocardiogram was performed and was 2 within normal limits. He was immediately heparinized in the ED and was taken to the 3 operating room emergently for exploratory laparotomy and SMA thrombectomy. 4

Institutional COVID-19 precautions and guidelines were implemented during intubation 5 and operation with appropriate personal protective equipment and gears. A midline 6 incision was made from the xiphoid to the pubic symphysis. The abdomen was entered 7 and explored. Upon exploration, a short segment of distal ileum appeared necrotic and 8 not viable. The rest of small bowel appeared viable. The SMA did not have a palpable 9

pulse. The SMA was dissected at the root of mesentery. After proximal and distal 10 controlled was obtained, a small transverse arteriotomy was made and thrombectomy was 11 performed with multiple passes of a #3 Fogarty catheter. The proximal thrombus was 12 removed, and pulsatile flow was established. The specimen was sent off to pathology. 13

Distal thrombectomy was performed with a #2 Fogarty catheter and good back bleeding 14 verified. The arteriotomy was then closed with interrupted 7-0 Prolene sutures. After 15 release of the clamps there were palpable pulses on the SMA proximal and distal to the 16 arteriotomy. Doppler signals were present on both the mesenteric and the antimesenteric 17 border of duodenum, jejunum, and proximal ileum. The distal ileum appeared necrotic 18 and not viable (Figure 2 ) therefore, a small bowel resection was performed with primary 19 end to end anastomosis. The abdomen was then closed. The patient tolerated the 20 procedure well and was extubated at the end of the procedure. Post operatively, the 21 patient was continued on heparin drip and then transitioned to therapeutic enoxaparin on 22 post-operative 3. Pathology report showed evidence of acute arterial thrombus. His 23 respiratory status remained stable during the hospital course. The oral intake was slowly 1 initiated after bowel function was restored on post-operative day 3. He continued to 2 improve and discharge home on anticoagulation with therapeutic enoxaparin for 3 3 months. After the patient was discharged, he was evaluated for hypercoagulability. The 4 preliminary results were negative so far. The patient 3 months follow up was with no 5 major complications. 6 7 Discussion 8 9 NCP pandemic continues to spread worldwide with significant morbidity and mortality in 10 patients with comorbodities. 6,7 There have been several reports indicating increased coagulation 11 activity in these patients. [1] [2] [3] Thrombotic events include autopsy-proven micro-vascular 12 thrombosis in a variety of vascular beds (pulmonary, hepatic, renal) 8 likely contributing to end 13 organ function deterioration, as well as large vessel thrombosis such as extensive DVTs or even 14 arterial thromboses resulting in stroke, myocardial infarction or lower extremity ischemia in 15 otherwise low risk patients. In a recently published study from China, it was reported that 25% of 16 all patients with COVID-19 infection admitted in the ICU developed acute deep venous 17 thrombosis (DVT) and that was associated with poor prognosis. 2 It has also been reported that 18 patients with active COVID-19 infection can manifest antiphospholipid antibodies which may 19 also contribute to hypercoagulopathy and thrombotic microangiopathy. 1 Elevated D-dimer 20 levels has been documented in hospitalized COVID-19 patients and there are early reports that 21 have linked higher D-dimer levels to worse outcomes. 4,10,11 Tang et al 5 reported 449 patients 22

with severe COVID-19 out of which 99 were treated with low molecular weight heparin. They 23 reported that anticoagulant therapy appears to be associated with better outcomes in severe 1 COVID-19 with markedly elevated D-dimer. Whether the increase in D-dimer level reflects a 2 more severe pro-thrombotic state or is the result of a more intense inflammatory response (likely 3 both), is not clear at this point. Although this pro-thrombotic state in COVID-19 patients is 4 documented and widely accepted, a consensus on if and when patients should receive 5 anticoagulation, what type, and for how long, has not been reached. It is not surprising, therefore, 6 that across geographical areas and institutions a wide spectrum of approaches to this issue are 7 reported, ranging from prophylactic DVT regimens for all hospital admitted COVID-19 patients 8 to therapeutic anticoagulation for all. Moreover, we were not able to find any reports related to 9 post-hospitalization thrombotic events. Following this patient presentation, we identified at least 10 four previously hospitalized COVID-19 patients who returned to the ED within 7 days post 11 discharge with symptomatic acute lower extremity DVT. Although the patient we report was 12 treated with prophylactic anticoagulation during his initial hospital stay, he developed acute 13 SMA thrombus one week after discharge. This suggests that the pro-thrombotic state in some 14 COVID 19 patients may continue well past the acute symptomatic phase. 15

In our institution, we have an anticoagulation protocol for the patient with COVID-19 126 these patients may benefit from an outpatient course of thromboprophylaxis but there is 1 no data to support that. 

Antiphospholipid Antibodies in Patients with Covid-19