Thrombocytopenia and splanchnic thrombosis after Ad26.COV2.S vaccination successfully treated with transjugular intrahepatic portosystemic shunting and thrombectomy

U.S, 31 May 2021, Dhoot et al, American Journal of Haematology

Summary

Our patient, a 24-year-old previously healthy male, presented with 10-day history of severe abdominal pain, nausea, vomiting, and decreased oral intake. He had been seen at urgent care 2 days earlier for similar symptoms, treated for presumed gastritis with belladonna alkaloids, phenobarbital, antacid, and viscous lidocaine, and had moderate improvement. He received the Ad26.COV2.S vaccine 11 days prior to onset of symptoms.

He had diffuse abdominal tenderness and mild thrombocytopenia (66 × 103/μl), leukocytosis (11.4 × 103/μl), elevated D-dimer (>5250 ng/ml) with normal hemoglobin 13.8 g/dl. That evening, he had worsening abdominal pain, maroon-colored emesis and drop in hemoglobin to 7.9 g/dl. He was transferred to the intensive care unit. Testing for SARS-CoV-2 was negative. Contrast enhanced computerized tomography (CT) showed extensive occlusive thrombosis of the portal, superior mesenteric (SMV), and splenic veins with severe bowel wall thickening concerning for venous ischemia. Brain magnetic resonance venography was negative for cerebral venous thrombosis. He was treated with heparin for 20 h and then bivalirudin due to concern for vaccine-induced thrombotic thrombocytopenia (VITT). He had esophagogastroduodenoscopy (EGD) on hospital Day 3 for hematemesis showing impressive congestive gastropathy, but no evidence of Mallory-Weiss tear, gastritis, ulcer or carcinoma. His platelet count ranged from 66 × 103/μl to 82 × 103/μl and he continued bivalirudin. Repeat abdominal imaging on Day 4 showed worsening of his extensive portal, SMV and splenic vein thrombosis, worsening small bowel thickening, and splenic hypoenhancement suggesting infarction.

He was transferred to our institution for evaluation by interventional radiology. We administered intravenous immunoglobulin (IVIG) 1 g/kg on Days 5 and 6. After multidisciplinary discussion, we proceeded with transjugular intrahepatic portosystemic shunt (TIPS)1 and thrombectomy to reduce the risk of further bowel ischemia and long-term complications of portal hypertension.2

We used intravascular ultrasound guidance with intracardiac echocardiography (ICE-Boston Scientific) to gain access to the thrombosed portal venous system. We advanced, with some difficulty, a wire through the thrombosed portal vein and SMV into the patent distal SMV tributaries and deployed a 10 mm diameter TIPS stent (Gore Viatorr). We suctioned clot from the portal vein and SMV with an Inari FlowTriever 16 (Inari Medical, Irvine CA) and used the AngioJet (Boston Scientific) thrombectomy device with 3 milligrams of tissue plasminogen activator to clear the splenic vein.

The following morning, he had complete resolution of abdominal pain. Post-procedure contrast enhanced computerized tomography demonstrated patency of the TIPS, SMV, and splenic veins, normal enhancement of the spleen and reduced small bowel wall thickening (Figure 2). The patient was evaluated by surgery as one loop of bowel had persistent wall thickening; but was managed non-operatively. His diet was advanced without any further pain.

image
Post-TIPS coronal image from CT performed on Day 1 after TIPS showing normal appearing portal, SMV and splenic veins (black arrows) flowing into a patent TIPS (white arrow). The spleen enhanced normally (asterisk) and the appearance of the bowel was improved

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