ST Elevation myocardial infarction with split LAD and bilateral acute limb ischemia in young patient with COVID-19

We report a 31-year-old overweight patient without any other cardiovascular risk factors, who presented with a 4-hour ST-segment elevation myocardial infarction (STEMI) with chest pain. An urgent coronary angiogram observed a single coronary artery anomaly (CAA) with a duplicated left anterior descending artery (LAD) with a thrombotic occlusion of a large diagonal branch. All other coronary arteries, including the split LAD, appeared angiographically normal. A primary percutaneous coronary intervention (PCI) was performed on the diagonal branch and 3 stents were deployed. Following the procedure, TIMI 3 flow was restored, and the patient experienced immediate relief from chest pain. No further electrocardiogram (ECG) changes were observed, and a transthoracic echocardiogram (TTE) after PCI revealed only mild left ventricular dysfunction. Twenty-four hours after admission, the patient developed a fever and was diagnosed with COVID-19. On day 4 of hospitalization, he developed bilateral thrombotic occlusion of both superficial femoral arteries, resulting in severe acute limb ischemia. This was treated aggressively with a quintuple antithrombotic regimen, initially comprising prasugrel, aspirin, and enoxaparin, followed by 24-hour intra-arterial local thrombolysis with r-tPA in addition to unfractionated heparin. Subsequently, manual thrombus aspiration and the placement of self-expanding stents in both femoral and popliteal arteries allowed partial restoration of distal flow. The patient later developed acute renal failure, shock, and multiorgan failure, ultimately succumbing to irreversible shock 13 days after hospital admission. COVID-19 can lead to multiple arterial thrombotic events, even in young patients without significant cardiovascular risk factors. In addition, we present a case of split LAD, a very rare congenital anomaly.