Background: As the second wave of COVID-19 is gripping the globe, liver transplant centers are increasingly receiving patients with a recent recovery from SARS-CoV-2 infection. Despite full clinical recovery, unexpected, unusual and potentially life-threatening complications in these patients are increasingly being recognized, one such patient is discussed here. By far, this is the first ever reported case of a COVID-19 recovered recipient developing recurrent thrombotic complications, which led us to change our routine anticoagulation protocols. Case presentation: We performed liver transplantation on a 51-year-old gentleman with decompensated liver disease 23-days after recovering from SARS-CoV-2 infection. At the time of surgery, he had no known sequalae of COVID-19. His routine preoperative work-up showed no underlying coagulation disorders. He underwent living related liver transplant (modified right lobe graft) during which, despite massive blood loss and a prolonged anhepatic phase, his thromboelastographic (TEG) parameters persistently revealed hypercoagulability. He received anti-coagulation according to our standard protocol which is based on aPTT ratio and INR. After a brief uneventful early post-operative period, he developed hepatic arterial thrombosis (HAT) on the 14 th postoperative day, and again after 4 days, both of which required surgical intervention. He was eventually discharged with normal graft function but was soon readmitted with recurrent HAT and necrosis of anterior sector with cholangiolar abscesses, further leading to graft loss, necessitating re-transplantation, from which he could not recover due to a rejection resistant to all conventional measures. Conclusions: : There is emerging evidence that patients following SARS-CoV-2 infection tend to be hypercoagulable. We believe that this hyper coagulability 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.
Recurrent hepatic artery thrombosis following living donor liver transplant as sequelae of SARS-CoV-2 infection: case report