Introduction: COVID-19 is a pandemic with numerous potential complications that are not yet fully understood. The virus has been implicated in complications from its pro-thrombotic tendencies. We present a case of COVID induced very late in-stent thrombosis presenting as an NSTEMI.

Case Presentation: A 66 year-old gentleman with a past medical history of coronary artery disease, myocardial infarction in 2006, with PCI to left circumflex, diabetes mellitus, and hypertension, presented to the ER with complaints of chest pain that had started 6 hours prior to hospital arrival. He was noted to have ST depressions in the inferior leads as well as elevated troponin (3.72 ref 0.00-0.03 NG/ML) and was diagnosed as having an NSTEMI. Patient was taken to the cath lab where angiography was performed. Left osteoproximal circumflex was noted to have in- stent thrombosis with 100% occlusion, TIMI flow of O. An aspiration thrombectomy was performed along with POBA of lesion. Post intervention TIMI Flow of 3 was recorded and patient was placed on Cangrelor and loaded with Brilinta for DAPT for 1+ year. During the procedure patient was noted to have increasing work of breathing along with altered mental status and was intubated for airway protection and transferred to the MICU. Shortly after a COVID-19 nasopharyngeal test was ordered and turned positive.

Final Diagnosis: COVID-19 has been reported to potentially cause a hypercoagulable state. Elevated/prolonged aPTT have been reported along with d-dimer elevation, both of which were present in our patient. Hypercoagulable state caused by SARS-COV-2 infection was likely the culprit behind this patients very late in-stent thrombosis presentation.

Management/Outcome/Follow-Up: Given high thrombus burden patient was started high intensity heparin for 24 hours post procedure. COVID-19 was treated with supportive measures and he was discharged home after two weeks.