TITLE:
Extraction of Atrial and Pulmonary Thrombi Using Angiovac Aspiration System with Transesophageal Echocardiography and Fluoroscopic Guidance
AUTHORS:
Saravanan Ramamoorthy, Saifeldin Ahmed Mahmoud, Kane High
KEYWORDS:
Cardiac Anesthesiology
JOURNAL NAME:
Open Journal of Anesthesiology,
Vol.7 No.6,
June
27,
2017
ABSTRACT: Surgical embolectomy is widely used to treat massive or submassive pulmonary thromboembolism and chronic thromboembolic pulmonary hypertension. [1]-[3] However, recently a new minimally invasive transvenous approach to clot evacuation using the AngioVac aspiration system (Vortex Medical, Norwell, Massachusetts) such as AngioVac aspiration system has been successfully used for retrieval of right atrial clot [4]-[6]. This is the first case report describing evacuation of trans-septal thrombus using an AngioVac aspiration system utilizing transesophageal echocardiograph (TEE) and fluoroscopic guidance. This case report also highlights the potential complications involved in AngioVac system which were readily diagnosed using TEE. We present a 66-year-old Caucasian female with a right atrial thrombus extending into left atrium through a patent for ovale (PFO) defect and a pulmonary artery thrombus. She underwent suction evacuation with an AngioVac aspiration system under TEE and fluoroscopic guidance. The right atrial thrombus extending into left atrium through a PFO was successfully evacuated through the PFO. However, the evacuation of the clot in the pulmonary artery was complicated by a rupture of the right ventricle requiring emergent sternotomy, cardiopulmonary bypass (CPB) and transient extracorporeal mechanical oxygenation (ECMO) support. The patient rapidly improved post-operatively and was discharged from hospital. Echocardiographic documentation of right heart thrombus and pulmonary emboli has poor prognostic implications. This report delineates the utility of TEE for visualization of cannula placement and real time aspiration of clots through the cannula. Potential complications associated with this technique are mechanical dislodge of thrombus from its attachment with subsequent embolization and rupture of cardiac chambers. Accessing the thrombus in the PA can be challenging and actual visualization of the cannula in the PA is often difficult and available only through TEE. This report highlights the utility of TEE for demonstrating trans-septal clot and the importance of precise positioning of cannula in avoiding complications. In spite of complications, AngioVac aspiration system under TEE and fluoroscopic guidance may become a safe alternative for surgical removal of intracardiac thrombi.