1Aljabriyah Alfutais, 1Abdulmajeed Bin Dahmash, 1Shaker Alshehri, 1Omar Bashir, 1Mohammad Arabi

1Vascular and Interventional Radiology Unit, Department of Medical Imaging, King Abdulaziz Medical City & King Abdullah Specialized Children’s Hospital, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia

 

Case Report:

COVID-19 primarily affects the respiratory system, from mild to severe symptoms like acute respiratory distress syndrome. Owing to a global inflammatory response and endothelial damage, COVID-19 may predispose to coagulation disorders that can lead to severe thrombotic incidents. We present an 88-year-old patient with history of diabetes, hypertension, end stage renal disease and asymptomatic COVID-19 infection. The patient presented to the emergency department complaining of abdominal pain and vomiting. Contrast abdominal CT scan indicated superior mesenteric artery (SMA) thrombosis with diffusely reduced bowel enhancement. The patient was considered high risk for surgical intervention. Consequently, she was referred to interventional radiology (IR) for endovascular revascularization of the SMA. Angiogram confirmed SMA thrombosis with the flow distally to jejunal branches and no flow seen to colonic branches via SMA. A 5 Fr infusion catheter was placed along the thrombus (7 cm long) and 4 mg of tissue plasminogen activator (tPA) was given to lace the thrombus at a rate of 1 mg/h for 16 hours. Subsequent angiography demonstrated significant residual thrombus within the SMA. Using left brachial access, a 90 cm 6-Fr sheath and successful thrombectomy performed with 6-Fr Penumbra device (PS; Penumbra, Alameda, CA, USA). Following this, a 7 mm x 36 mm Valeo stent (Bard Inc., New Providence, NJ, USA) was deployed at the origin of SMA to treat residual stenosis. Final angiogram demonstrated excellent flow through the SMA and its main branches. Patient developed left brachial artery vascular sheath related dissection and thrombosis which required stent graft placement (5mm X 5cm, Viabahn stent W. L. Gore, Flagstaff, Ariz, USA). This case demonstrates that arterial thrombotic events in the context of COVID 19 may be treated with endovascular techniques to obviate the need for surgical interventions.