Abstract 257: Heavy Clot Burden Despite Enoxaparin Therapy In The Setting Of Covid Pneumonia

Abstract

Case: A 71-year-old male with a past medical history of hypertension, tobacco use, and hyperlipidemia was admitted to the hospital for COVID-19 pneumonia. Initial CT scan was negative for a pulmonary embolism. He was intubated on day 4, and his follow-up CT showed bilateral pulmonary emboli despite prophylactic Enoxaparin 40 mg subcutaneously daily since admission. He was subsequently put on a therapeutic dose of 1mg/kg every 12 hours. The following day he was found to have a pneumothorax that necessitated a chest tube, and that same evening, he developed acute lower limb ischemia in the setting of therapeutic anticoagulation for 24 hours. Arterial doppler ultrasound revealed extensive occlusive thrombus in the major arteries of the left lower extremity. Emergent thromboembolectomy of the left iliac artery, superficial femoral artery, popliteal artery, and tibial artery and a 4-compartment fasciotomy on the lower leg was performed, but 2 days later he necessitated an above knee amputation. Thereafter, the patient’s right lower extremity became cool, but an arterial doppler showed collateral flow suggestive of chronic arterial disease. Discussion: This patient with no known history of prior blood clots or arrhythmias sustained heavy clot burden and limb amputation despite prophylactic and eventual therapeutic anticoagulation and not to mention barotrauma. Notably, his right lower extremity became cool concerning for micro-coagulopathy in the setting of an unremarkable ultrasound. Little guidance is available regarding anticoagulation strategy on individuals with COVID, let alone those at risk of blood clots. The question remains as to whether practitioners need to anti-coagulate all critically ill patients with COVID-19 more aggressively, anti-coagulate individuals at risk for atherosclerotic disease more aggressively, or consider agents such as antiplatelet agents for arterial thrombosis prophylaxis.