Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 8  |  Issue : 5  |  Page : 75-76

Early catheter-directed thrombolysis without bowel resection in acute mesenteric ischaemia for a symptomatic COVID-19 patient


1 Department of Vascular and Endovascular Surgery, Holy Spirit Hospital, Mumbai, Maharashtra, India
2 Department of General Medicine, Holy Spirit Hospital, Mumbai, Maharashtra, India
3 Department of Radiodiagnosis, Holy Spirit Hospital, Mumbai, Maharashtra, India

Date of Submission11-Sep-2020
Date of Acceptance11-Nov-2020
Date of Web Publication30-Aug-2021

Correspondence Address:
Aniruddha Sanjoy Bhuiyan
Department of Vascular and Endovascular Surgery, Holy Spirit Hospital, Mumbai, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijves.ijves_128_20

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  Abstract 


Newer evidence states that COVID-19 pneumonia induces a hypercoagulable state leading to vascular and microvascular thrombotic events. Acute mesenteric ischaemia (AMI) is a potentially fatal vascular emergency with overall mortality of 60%–80%.However, till date, only a few cases of superior mesenteric artery thrombosis in COVID-19 positive patients are reported and most have succumbed to COVID-19 or mesenteric ischemia. Physicians treating COVID-19 usually treat respiratory symptoms and may completely overlook any other uncommon pathology. This case report emphasizes that a patient with early detection and management of acute mesenteric ischaemia being symptomatic for COVID-19 can avoid major bowel surgery and negates any morbidity or mortality associated with the same.

Keywords: Catheter directed thrombolysis, COVID-19, mesenteric vascular ischaemia, superior mesenteric artery thrombosis


How to cite this article:
Bhuiyan AS, Balani P, Dalal VN, Maheshwari GS. Early catheter-directed thrombolysis without bowel resection in acute mesenteric ischaemia for a symptomatic COVID-19 patient. Indian J Vasc Endovasc Surg 2021;8, Suppl S1:75-6

How to cite this URL:
Bhuiyan AS, Balani P, Dalal VN, Maheshwari GS. Early catheter-directed thrombolysis without bowel resection in acute mesenteric ischaemia for a symptomatic COVID-19 patient. Indian J Vasc Endovasc Surg [serial online] 2021 [cited 2021 Dec 1];8, Suppl S1:75-6. Available from: https://www.indjvascsurg.org/text.asp?2021/8/5/75/324928




  Introduction Top


COVID-19 has been a tyrant for the year 2020 and continues to be so, even though vaccines have started been administered worldwide. Acute mesenteric artery ischemia (AMI) tends to be destructive on its own with large multifocal bowel necrosis and gangrene, usually leading to death. COVID-19 and AMI seem to be a deadlier combination knowing the destructive nature of both alone.[1],[2],[3],[4] However, early detection and treatment of both can be quite comfortable for both doctor and patient, as we have shown in this case report.

We report the first symptomatic COVID-19 patient presenting with bowel ischemia and mesenteric arterial thrombosis treated early with catheter-directed thrombolysis and thrombus aspiration without bowel gangrene or need for laparotomy.


  Case Report Top


A 37-year-old COVID-19 positive male with no preexisting comorbidities, presented in the late hours with severe abdominal pain not resolving with medication and associated intermittent episodes of vomiting. He had irregular spikes of 102F fever for 72 h but was hemodynamically stable. Clinical examination showed a soft abdomen with mild guarding over epigastric and paraumbilical regions. Lactate and procalcitonin were borderline elevated. He was started on symptomatic treatment, and blood investigations were called for. However, the pain did not subside and continued to aggravate even with high doses of nonsteroidal anti-inflammatory drugs and opioid analgesics.

Contrast enhanced computed tomography (CT) with angiography of the abdomen showed thrombus at the origin of the superior mesenteric artery (SMA) extending into the jejunal arcades with impending gangrene of bowel [Figure 1]a. Two-dimensional echocardiography and CT angiogram of the whole aorta showed no intracardiac or intraaortic thrombus. He was urgently taken up for catheter-directed thrombolysis overnight [Figure 1]b. Injection actilyse (recombinant human tPA), 8 mg given bolus followed by 1 mg/h was given via 4F 10 cm Cragg Mcnamara Thrombolysis Infusion Catheter into the thrombosed SMA. Reshoot angiogram with thrombus aspiration done on the postoperative day 1 showed complete resolution of thrombosis with opening up of jejunal arcades and the main SMA trunk [Figure 1]c and [Figure 1]d. All the hardware was removed, and puncture sites secured. The patient was transferred postoperatively to the COVID isolation ward and observed as per hospital protocol. He passed stools the very next day with no abdominal symptoms. Diagnostic laparoscopy planned post catheter-directed thrombolysis was withheld due to the same. He was started orally from the postoperative day 3 and was completely discharged from the hospital after 5 days stay in the COVID-19 ward. The prothrombotic workup done was unremarkable. Postoperative CT Abdomen showed mild bowel wall thickening supplied by the jejunal arcades, which resolved after 2 weeks.
Figure 1: (a) Computed tomography angiogram showing superior mesenteric artery thrombosis with jejunal thrash. (b) Digital subtraction angiography image of superior mesenteric artery thrombus. (c) Post thrombolysis jejunal and ilial arcades. (d) Postthrombolysis superior mesenteric artery main trunk

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Materials used

7F sheath, 0.035 Terumo guidewire, SHK 5F catheter, 0.014” command wire, injection actilyse, 7F Clot aspiration catheter.


  Discussion Top


In the course of COVID-19 disease, hypoxia, inflammatory mediators, thrombocythemia, immobilization, sepsis, liver injury secondary to angiotensin-converting enzyme 2 receptor expression may predispose to arterial and venous thrombosis.[5],[6] Microthrombi and inflammatory mediators are postulated to cause mesenteric ischemia as COVID-19 is said to cause endothelial damage. Patients with severe COVID-19 complicated by AMI may present with abdominal pain, nausea/vomiting, diarrhea, abdominal distention, or worsening systemic status (sepsis).

Many case reports worldwide have shown high morbidity and mortality when COVID-19 and mesenteric arterial thrombosis occur together, usually leading to large bowel resections and death. Usually, COVID-19 treating physicians have more focus toward the occurrence of lower respiratory tract symptoms and may neglect bowel symptoms, which tend to be more urgent to manage. Once organ failure sets in, the scenario ends up more frequently as a vicious cycle.

Our patient primarily came with severe abdominal pain not responding to medications, and high fever, which made us more suspicious for COVID-19. Early CT Angiogram of the abdomen gave us the diagnosis of Acute SMA Thrombosis with jejunal thrash and impending gangrene of the bowel. Early diagnosis and efficient thrombolysis resulted in better bowel salvage with complete resolution of symptoms on the postoperative day 1 with the patient starting oral intake from the postoperative day 3.

Early management of arterial thrombosis compromising blood flow even with COVID-19 can help in reducing the morbidity of COVID-19 and thus reduce overall mortality rates even while we remain trapped in the web of this PANDEMIC !!!

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Heys SD, Brittenden J, Crofts TJ. Acute mesenteric ischaemia: The continuing difficulty in early diagnosis. Postgrad Med J 1993;69:48-51.  Back to cited text no. 1
    
2.
Beccara L, Pacioni C, Ponton S, Francavilla S, Cuzzoli A. Arterial mesenteric thrombosis as a complication of SARS-CoV-2 infection. Eur J Case Rep Intern Med 2020;7:001690.  Back to cited text no. 2
    
3.
de Barry O, Mekki A, Diffre C, Seror M, El Hajjam M, Carlier RY. Arterial and venous abdominal thrombosis in a 79-year-old woman with COVID-19 pneumonia. Radiol Case Rep 2020;15:1054-7.  Back to cited text no. 3
    
4.
Ignat M, Philouze G, Aussenac-Belle L, Faucher V, Collange O, Mutter D, et al. Small bowel ischemia and SARS-CoV-2 infection: An underdiagnosed distinct clinical entity. Surgery 2020;168:14-6.  Back to cited text no. 4
    
5.
Pan L, Mu M, Yang P, Sun Y, Wang R, Yan J, et al. Clinical characteristics of COVID-19 patients with digestive symptoms in Hubei, China: A descriptive, cross-sectional, multicenter study. Am J Gastroenterol 2020;115:766-73.  Back to cited text no. 5
    
6.
Klok FA, Kruip MJ, van der Meer NJ, Arbous MS, Gommers DA, Kant KM, et al. Incidence of thrombotic complications in critically ill ICU patients with COVID-19. Thromb Res 2020;191:145-7.  Back to cited text no. 6
    


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