Case Description:
An 84-year-old African American female with past medical history of end-stage renal disease (ESRD) on hemodialysis through a left lower extremity arteriovenous graft, type 2 diabetes mellitus and atrial fibrillation on warfarin came to the emergency department after she was found to have temperature of 101°F at her dialysis center. She was complaining of mild nonproductive cough but denied any shortness of breath or any sick contacts. In emergency department, her temperature was 99.1°F, blood pressure 146/77 mmHg, heart rate 73 beats/minute, respiratory rate 17/minute and oxygen saturation 98% on room air. She was diagnosed with COVID-19 detected by polymerase chain reaction (PCR) and eventually discharged home. She came back again 1 week later with shortness of breath and was admitted due to hypoxemia. Her physical examination was unremarkable other than crackles in lungs bilaterally. Her electrolytes were normal. Her INR was sub-therapeutic at 1.4. Her platelet count was 114,000/mm3, prothrombin time (PT) 17.8 seconds (reference range [RR]: 11.9-14.7 seconds), activated partial thromboplastin time (aPTT) 38.4 seconds (RR: 23.3-35.3 seconds) and D-dimer 3.28 mcg/mL (RR: <0.4 mcg/mL). Her severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) PCR was again positive. She had elevated venous pressures during hemodialysis and hence doppler was ordered which showed homogenous echoes suggestive of AV graft thrombosis. She was started on heparin drip. Angiography and intravascular ultrasound was performed which showed thrombosed AV graft. (Figure 1a,1b) Thrombectomy and stent placement was performed successfully with good flow post procedure. (Figure 1c,1d) She had uneventful hemodialysis afterwards and was discharged. A day after discharge, she came back again with diarrhea. Her repeat SARS-CoV-2 PCR was still positive. Her INR was 1.9. She was again found to have high venous pressures during hemodialysis and hence doppler was repeated which was positive for recurrent thrombosis of AV graft. She was started on heparin drip and vascular surgery decided to place a tunneled dialysis catheter and hold thrombectomy till her SARS-CoV-2 PCR turns negative, due to concerns of hypercoagulability in the setting of COVID-19.