Recurrent Hepatic Artery Thrombosis Following Living Donor Liver Transplant as Sequelae of SARS-CoV-2 Infection—a Case Report

Abstract

As the second wave of COVID-19 disease is gripping the globe, liver transplant centers are increasingly receiving patients recovered from SARS-CoV-2 infection in recent few weeks. Unexpected complications in these patients are increasingly being recognized. We performed liver transplantation on a 51-year-old gentleman with decompensated liver disease 23 days after recovering from a mild SARS-CoV-2 infection. Surprisingly, despite massive blood loss and a prolonged anhepatic phase, his thromboelastographic (TEG) parameters persistently revealed hypercoagulability. After a brief uneventful early post-operative period, he developed hepatic arterial thrombosis on the 14th post-operative day, and again after 4 days, both of which required surgical intervention. Following discharge, the artery was thrombosed again which was only picked up when he developed a cholangiolar abscess, leading to graft loss necessitating re-transplantation. There is a lot of evidence suggesting that patients with SARS-CoV-2 infection tend to be hypercoagulable. We believe that this hypercoagulability might have played a significant role in the development of hepatic arterial thrombosis and eventual graft loss in this patient. This highlights the importance of revisiting anticoagulation protocols in liver transplant recipients recovered from COVID-19 and base them on TEG rather than routine parameters such as INR and APTT, which are routinely deranged in such patients.

Does COVID-19 infection significantly affect liver transplantation? Results of liver transplantation in the COVID-19 era at a single, high-volume centre

“… 11 15 A recurrent form of HAT as a result of COVID-19 was reported in India, which shows the severity of HAT by which the cases might be affected. 16 …”

“…11 15 A recurrent form of HAT as a result of COVID-19 was reported in India, which shows the severity of HAT by which the cases might be affected. 16 Our analysis was carried out after the cases and controls were matched; moreover, as MELD and CHILD scores predict mortality rates, we furthered research using adjusted regression models. These models yielded significant results for certain parts, indicating a significant correlation between early postoperative mortality rates and COVID-19 infection.…”

Update on Covid-19: vaccines, timing of transplant after COVID-19 infection and use of positive donors

“…Cases of successful liver transplants 2–4 weeks after infection have been anecdotally reported early in the pandemic but are likely to become more frequent given occurrence of reinfections [65]. Some concerns persist regarding hypercoagulable state and risk of arterial thrombosis [66]. When a candidate is found to be positive, serial cycle threshold (Ct) values can be used as a tool to time infection, with Ct values above 32–34 being a marker of low infectivity and potentially lower surgical or complication risk [67].…”

Favorable experience of transplant strategy including liver grafts from COVID‐19 donors: One‐year follow‐up results

“…First of all, COVID-19 donors were allocated to patients with life-threatening organ dysfunction or multifocal HCC which could influence a higher risk of vascular complications.On the other hand, there is a growing pool of data, which suggests patients infected by SARS-CoV-2 virus tend to be hypercoagulable. Some reports have come with evidence of acute arterial thrombosis in patients infected with SARS-CoV234 and cases of post-transplantation HAT after recovering from pre-LT SARS-CoV-2 infection have been already published 35. A Spanish experience36 raised the concern as well that NAT+ donor organs could augment hypercoagulability and graft thrombosis through COVID-related endothelial injury: from December 2020 to May 2022, 69 patients underwent transplant from NAT+ donors and two kidney recipients had graft loss due to renal vein thrombosis and hypoperfusion.…”