Recurrent thrombosis of an arteriovenous fistula as a complication of COVID-19 in a chronic hemodialysis patient: A case report.

Patients with end-stage kidney disease are at increased risk of death from coronavirus disease 2019 (COVID-19). In addition, severe COVID-19 has been associated with an increased risk of arterial and venous thromboses. In this report, we describe the case of a hemodialysis patient who developed an otherwise-unexplained thrombosis of an arteriovenous fistula during a symptomatic COVID-19 infection. Despite prompt treatment with three technically successful thrombectomies along with systemic intravenous heparin and two rounds of catheter-directed thrombolysis with tissue plasminogen activator, the fistula rapidly re-thrombosed each time and he required tunneled dialysis catheter placement. He subsequently required admission for hypoxemia from COVID-19 pneumonia and ultimately developed a catheter-related blood stream infection that likely contributed to his death. As the fistula had been previously well functioning and no angiographic explanation for the thrombosis was found, we speculate in this case the recurrent thromboses were related to the hypercoagulable state characteristic of severe COVID-19. Interventionalists performing hemodialysis access procedures should be aware of the prothrombotic state associated with COVID-19 and should consider it when deliberating how to best plan and approach access interventions in patients with symptomatic COVID-19.