Background:

COVID 19 is associated with adverse thrombotic events. We present a unique case of STEMI and ALI.

Case:

A 61-year-old male presented with chest pain, dyspnea, and subacute left leg pain. Physical examination revealed respiratory distress and a non-viable left leg. EKG revealed inferior STE. Laboratory studies were pertinent for positive SARS-CoV-2 PCR. Emergency coronary angiography was performed due to worsening respiratory failure and thrombotic occlusion of the RCA was observed. Reperfusion was achieved with thrombectomy and two drug-eluting stents. Iliac angiography subsequently revealed bilateral CIA thrombosis with occlusion of the left CIA. The patient underwent surgical thrombectomy and above-knee amputation but developed refractory shock and expired.

Decision-making:

This case presents a complex dilemma with simultaneous STEMI and ALI secondary to COVID 19. Thrombolytic therapy was contraindicated due to left leg non-viability. Yet, it begs the question: if the patient had presented with a viable extremity, would systemic thrombolysis have been an appropriate initial therapy?

Conclusion:

Initial choice of therapy may be challenging in patients with COVID 19 and thrombosis involving multiple arterial territories. Although data is lacking, systemic thrombolysis should be considered. Invasive revascularization can then be considered in cases of suboptimal response.

Footnotes