Emergent aspiration thrombectomy for thrombus in transit and pulmonary embolism using AngioVac

A 68-year-old man presented to a local hospital with a sudden-onset pain and weakness in the lower extremities. The initial workup indicated disseminated prostate cancer. On the 5th day of hospitalization, he developed dyspnea, tachycardia 124 bpm, and hypotension 85/60 mm Hg with elevated levels of troponin I (2.02 ng/ml; reference range [RR], <⁠0.05 ng/ml) and N-terminal pro–B-type natriuretic peptide (NT-proBNP; 5053 pg/ml; RR <⁠125 pg/ml). Imaging studies revealed bilateral proximal pulmonary embolism (PE) with severe right heart strain and interatrial thrombus in transit (TIT) (Figure 1A and 1B). Initial therapy with unfractionated heparin was introduced. The PE response team discussed the patient’s case and qualified him for catheter-directed mechanical aspiration thrombectomy (CDMT), for which he was transferred to our center. Intensive vasopressor therapy was initiated with noradrenaline, dobutamine, arginine vasopressin, and levosimendan.

The left common femoral vein (CFV) access was used to insert a short 18 Fr extracorporeal cannula (Edwards, Irvine, California, United States) for blood reinfusion from the AngioVac circuit. The procedure started through a right CVF approach obtained with the GORE Flex 26 Fr sheet. The AngioVac system 22 Fr type 180 (AngioDynamics, Latham, New York, United States) was advanced into the right atrium, throwing Gore Flex sheet over the Amplatz Super Stiff guidewire. The device tip was placed close to the TIT under transesophageal echocardiographic and fluoroscopic guidance (Figure 1C and 1D). The extracorporeal circuit primed with saline and equipped with a centrifugal pump (RotaFlow, Getinge, Germany) was started with an initial speed of 500 rotations per minute (rpm) and increased to over 3000 rpm. Subsequently, successful clot aspiration was performed with a complete TIT removal. The pulmonary arteries (PAs) were accessed using a 6 Fr, 100 cm pigtail catheter. The initial PA pressures were elevated at 46/13/36 mm Hg (systolic [s]/ diastolic [d]/mean [m], respectively). Pulmonary angiography confirmed bilateral PE in proximal PAs. Afterward, the AngioVac catheter was introduced into the right PA on the Amplatz Super Stiff wire close to the embolus and the aspiration was repeated. The procedure was then replicated in the left PA (Figure 1E). The procedure resulted in clot burden reduction and hemodynamic improvement (the PA pressure dropped to 38/10/30 mm Hg [s/d/m], respectively), without notable blood loss (Figure 1F). The patient was independent of vasopressors within 24 hours and troponin I and NT-proBNP levels decreased to 0.93 ng/ml and 521 pg/ml, respectively. A 48-hour postprocedural control imaging demonstrated decreased clot burden in the PAs with no definite atrial thrombus and reduction of the right heart strain (Figure 1G and 1H). The patient was discharged in a good general condition on the 3rd day after the procedure on anticoagulation with a low-molecular weight heparin. There were no adverse events during a 3-month follow-up.

TIT is associated with paradoxical brain embolization and high mortality rate exceeding 45%.¹ TIT can be detected in less than 2% of patients with PE.² The treatment of choice for PE and concomitant TIT depends on individual assessment, considering surgical embolectomy, systemic thrombolysis, or CDMT.^3-5 The AngioVac is a completely percutaneous technique of large clot extraction, with no risk of the thrombus fragmentation, which obviates surgery, particularly in patients with severe coexisting diseases.² We demonstrated the feasibility of the AngioVac system in CDMT of central PE and TIT.