S5753 A Double Hit: COVID-19-Associated Hepatic Artery Thrombosis Post-Transplant in PSC-ESLD

Introduction: COVID-19 is associated with a hypercoagulable state that can trigger severe thrombotic events, particularly in high-risk patients. Primary sclerosing cholangitis (PSC) is a chronic liver disease that may progress to end-stage liver disease (ESLD), often requiring orthotopic liver transplantation (OLT). While hepatic artery thrombosis is a rare but serious post-transplant complication, its occurrence following COVID-19 infection is exceptionally uncommon. This case highlights COVID-related hepatic artery thrombosis in a PSC-ESLD patient post-OLT. Case Description/Methods: A 45-year-old White man with a history of gastroesophageal reflux disease (GERD), celiac disease, and PSC-associated end-stage liver disease (ESLD) complicated by ascites, esophageal varices, and hepatocellular carcinoma (HCC) underwent OLT. Four weeks post transplant, this patient tested positive for COVID-19, presenting to the emergency department with fatigue, headache, weakness, and fever. Doppler ultrasound revealed absent blood flow in the right and left hepatic arteries. He was taken for exploratory laparotomy, which showed severe stenosis of the proximal hepatic artery and a lobulated fluid collection in the left hepatic lobe. Given these findings and concern for a thrombotic etiology, a hypercoagulability workup was initiated, revealing mildly decreased levels of protein C, protein S, and antithrombin. Testing for prothrombin gene mutation, Factor V Leiden, and antiphospholipid antibodies was negative, as was an extensive secondary hypercoagulability workup. Blood cultures were persistently positive for Citrobacter and E. coli. He was initially treated with intravenous Meropenem, then transitioned to Ertapenem. Repeat cultures were negative, and an abscess drain was placed. Due to hepatic artery thrombosis, he was re-listed for liver transplantation with MELD exception points. He was discharged home on antibiotics and underwent a successful second OLT the following week. Discussion: While COVID-19 is often asymptomatic, it can cause serious complications in patients with underlying liver disease. In rare instances, the combination of COVID-19 and ESLD can result in life-threatening outcomes. Our patient, who had PSC-related ESLD and had recently undergone a liver transplant, remained clinically stable until contracting COVID-19. Shortly after, he developed hepatic artery thrombosis, leading to acute liver failure and sepsis. This case underscores a rare but severe complication of COVID-19 in a post-transplant patient, necessitating a second liver transplant.