Recurrent arteriovenous graft thrombosis in COVID-19 positiv
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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/min, respiratory rate 17/min, 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 s, activated partial thromboplastin time (aPTT) 38.4 s, and D-dimer 3.28 mcg/ml. Her 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 (bolus at 70 units/kg and drip 15 units/kg/h). Angiography and intravascular ultrasound were performed which showed thrombosed AV graft. Thrombectomy and stent placement were performed successfully with good flow post-procedure.

She had uneventful hemodialysis afterward 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 at the same previous rate 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.

COVID-19-associated coagulopathy, Sub-therapeutic INR, history of end-stage renal disease, and diabetes mellitus placed our patient at higher risk for recurrent AV fistula thrombosis.