Saint Michael's Medical Center Harrison, NJ, United States
Aditya Patel, MD1, Muhammad Hussain, MD1, Ruhma Ali, MD1, Saraswathi Lakkasani, MD2, Theodore Dacosta Jr., MD2, Yatinder Bains, MD2 1Saint Michael's Medical Center, Harrison, NJ; 2Saint Michael's Medical Center, Newark, NJ
Introduction: Mesenteric artery thrombosis and antiphospholipid syndrome (APS) is a rare combination but must be suspected in patients with high clinical suspicion. Treatment options of mesenteric ischemia include open surgical or endovascular revascularization. Medical therapy can be given in patients with incomplete duodenal obstruction, multiple comorbidities and moderate symptoms. Here we present a case of rethrombosis of superior mesenteric artery (SMA) in a patient with APS, history of SMA thrombosis with stent placement and COVID 19 while being on direct oral anticoagulant (DOAC).
Case Description/Methods: 56 year old male with PMH of APS, peripheral arterial disease, deep vein thrombosis (DVT) s/p inferior vena cava filter, chronic mesenteric ischemia s/p small bowel resection complicated by SMA thrombosis treated with stent placement, left atrial thrombosis (was on xarelto) presented with intermittent abdominal pain in the lLUQ for last 2 weeks, aggravated 20 min after eating and radiated to the flanks, associated with non bloody non bilious vomiting and chills. He also tested PCR positive for COVID but was asymptomatic.. On admission, vitals were normal. Lipase was moderately elevated but criteria for pancreatitis were not met. CT scan with oral and IV contrast showed occluded superior mesenteric artery stent with distal reconstitution of the vessel via collaterals from celiac and inferior mesenteric artery suggesting chronicity of the occlusion. Invasive radiology was also consulted, but considering developed collaterals and no bowel ischemia, no intervention was attempted. Xarelto was discontinued. Patient was started on heparin drip and then bridged to warfarin before discharge.
Discussion: DOAC for patients with APS can lead to increased risk of thrombotic events as per European wide review. Our patient has multiple etiologies for development of restenosis including Covid 19, APS, left atrial thrombosis and the use of direct acting anticoagulation. Our case is compelling because of rethrombosis of SMA while being on DOAC in APS and COVID 19 itself is a thrombophilic condition, which might be contributing to the cause.
Figure: CT Abdomen Pelvis with oral and IV contrast showing filling defect in Superior Mesenteric Artery
Aditya Patel indicated no relevant financial relationships.
Muhammad Hussain indicated no relevant financial relationships.
Ruhma Ali indicated no relevant financial relationships.
Saraswathi Lakkasani indicated no relevant financial relationships.
Theodore Dacosta Jr. indicated no relevant financial relationships.
Yatinder Bains indicated no relevant financial relationships.
Aditya Patel, MD1, Muhammad Hussain, MD1, Ruhma Ali, MD1, Saraswathi Lakkasani, MD2, Theodore Dacosta Jr., MD2, Yatinder Bains, MD2. P2007 - Superior Mesenteric Artery Thrombosis Associated With Antiphospholipid Syndrome and COVID-19, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.