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.