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On The Edge Of Embolization - Multiprong Successful Endovascular Removalmanagement Of A Large Right Atrial Thrombus
Dylan Brooks, MD, Tam Huynh, MD.
Houston Methodist Hospital, Houston, TX, USA.
Large right atrial thrombi carry a high risk of embolization and mortality, particularly when associated with concomitant pulmonary embolism. Traditional management options include systemic thrombolysis, open thrombectomy, or catheter-directed therapies. The AngioVac aspiration thrombectomy system (AngioDynamics, Latham, NY) has emerged as a minimally invasive alternative for mechanical removal of mobile intravascular and intracardiac thrombus, providing continuous aspiration and filtration via a venovenous bypass circuit.
We report the successful endovascular management of a large right atrial thrombus in a 70-year-old male with an intermediate-high risk pulmonary embolism. The patient presented with two weeks of progressive exertional dyspnea and fatigue. Transthoracic echocardiography demonstrated a large, mobile right atrial thrombus, and CTA of the chest confirmed bilateral pulmonary emboli. He was referred for urgent intervention.
Percutaneous access was obtained via the right internal jugular and femoral veins. A large-bore AngioVac thrombectomy catheter was advanced to the inferior vena cava-right atrial junction and connected to a venovenous bypass pump. We used intraoperative transthoracic echocardiogram to engage the thrombus with the catheter and an extensive effort was made to aspirate the atrial thrombus at maximal flow rates without successful debulking and aspiration. Given the risk of distal migration of large solid thrombus upon device withdrawal, we elected to deploy an inferior vena cava filter via left jugular approach. We withdrew the thrombectomy catheter to the inferior vena cava and deployed a retrievable inferior vena cava filter central to the thrombectomy catheter.
Following filter deployment, the AngioVac catheter and sheath were withdrawn en bloc to minimize funnel collapse and embolization risk. A large, organized thrombus was successfully extracted. We then performed mechanical thrombectomy of bilateral pulmonary emboli via trans jugular access. The patient tolerated the procedure well, was transitioned to oral anticoagulation, and discharged home 2 days postoperatively. Pathology confirmed benign thrombus.
This case highlights the potential role of combined aspiration thrombectomy and embolic protection in the management of right atrial thrombus, particularly when initial aspiration fails. Placement of an inferior vena cava filter as a distal safeguard enabled safe removal of the AngioVac device with retrieval of the large organized clot mitigating potential massive embolization and cardiopulmonary collapse.
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