Thrombosis with Thrombocytopenia Syndrome After Administration of AZD1222 or Ad26.COV2.S Vaccine for COVID-19: A Systematic Review

Usama Waqar, Shaheer Ahmed, Syed M.H.Ali Gardezi, Muhammad Sarmad Tahir, Zain ul Abidin, Ali Hussain, Natasha Ali, Syed Faisal Mahmood

Research output: Contribution to journalReview articlepeer-review

11 Citations (Scopus)


Background: Cases of thrombosis with thrombocytopenia syndrome (TTS) have been reported following vaccination with AZD1222 or Ad26.COV2.S. This review aimed to explore the pathophysiology, epidemiology, diagnosis, management, and prognosis of TTS. Methods: A systematic review was conducted to identify evidence on TTS till 4th September 2021. Case reports and series reporting patient-level data were included. Descriptive statistics were reported and compared across patients with different sexes, age groups, vaccines, types of thrombosis, and outcomes. Findings: Sixty-two studies reporting 160 cases were included from 16 countries. Patients were predominantly females with a median age of 42.50 (22) years. AZD1222 was administered to 140 patients (87·5%). TTS onset occurred in a median of 9 (4) days after vaccination. Venous thrombosis was most common (61.0%). Most patients developed cerebral venous sinus thrombosis (CVST; 66.3%). CVST was significantly more common in female vs male patients (p = 0·001) and in patients aged <45 years vs ≥45 years (p = 0·004). The mortality rate was 36.2%, and patients with suspected TTS, venous thrombosis, CVST, pulmonary embolism, or intraneural complications, patients not managed with non-heparin anticoagulants or IVIG, patients receiving platelet transfusions, and patients requiring intensive care unit admission, mechanical ventilation, or inpatient neurosurgery were more likely to expire than recover. Interpretation: These findings help to understand the pathophysiology of TTS while also recommending diagnostic and management approaches to improve prognosis in patients. Funding: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Original languageEnglish
JournalClinical and Applied Thrombosis/Hemostasis
Publication statusPublished - Dec 2021


  • Ad26.COV2.S vaccine
  • COVID-19 vaccines
  • ChAdOx1 COVID-19 vaccine
  • thrombosis with thrombocytopenia syndrome
  • vaccine-induced immune thrombotic thrombocytopenia


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