Surgical and Endovascular Management of Aortic Thrombosis in COVID-19 and Vaccine-Induced Immune Thrombotic Thrombocytopenia

Rojan Abdollahzadeh Mirali,1 Seyedh Saba Ramazannia Toloti,2 Yasamin Bigdeli,3 Asal Ebrahimi,4 Yasamin Roointanpour,2 Meghdad Ghasemi Gorji1,2,5 1Department of Vascular Surgery, Shiraz University of Medical Sciences, Shiraz, Iran; 2Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran; 3Student Research Committee, Faculty of Medicine, Qom University of Medical Sciences, Qom, Iran; 4Student Research Committee, Azad Tehran University of Medical Sciences, Tehran, Iran; 5Vascular Surgery at Shiraz University of Medical Sciences, Shiraz, IranCorrespondence: Yasamin Bigdeli, Email bigdeliasieh4@gmail.com Meghdad Ghasemi Gorji, Email meghdad.ghasemi.gorji@gmail.comBackground: COVID-19 has been associated with a hypercoagulable state, leading to various thrombotic complications, including aortic thrombosis, a rare but severe manifestation requiring surgical intervention. Additionally, vaccine-induced immune thrombotic thrombocytopenia (VITT), linked to adenoviral vector vaccines, presents unique surgical challenges due to a heightened risk of thrombosis and bleeding. This review focuses on the surgical management of COVID-19-associated aortic thrombosis and VITT-related large-vessel occlusions.Results: Surgical intervention in COVID-19-associated aortic thrombosis depends on thrombus burden, patient stability, and associated comorbidities. Open thrombectomy, aortic bypass, and hybrid endovascular techniques have been employed, with perioperative anticoagulation being critical to prevent recurrence. High thrombus burden cases often require open repair, while endovascular approaches are preferred in high-risk patients. Mortality rates remain elevated (up to 30%), with post-surgical complications including recurrent thrombosis and limb loss. In VITT cases, surgical revascularization is complicated by thrombocytopenia and a prothrombotic state, necessitating non-heparin anticoagulation and close hematologic monitoring. Delayed diagnosis and inappropriate anticoagulation significantly worsen outcomes.Conclusion: The surgical management of aortic thrombosis in COVID-19 and VITT patients requires a multidisciplinary approach, incorporating vascular surgery, hematology, and intensive care. Early intervention with individualized surgical and anticoagulation strategies is crucial in optimizing outcomes. Further research is needed to refine surgical decision-making, improve postoperative anticoagulation protocols, and enhance patient survival in these complex thrombotic conditions.Keywords: aortic thrombosis, COVID-19, vaccine-induced immune thrombotic thrombocytopenia, VITT, surgical management, endovascular therapy, thrombectomy, vascular surgery, thrombotic complications