Novel Strategies to Overcome a Challenging Mechanical Thrombectomy of a Saddle Pulmonary Embolism
Presenter
Laurie Bossory, MD, The Ohio State University Wexner Medical Center, Columbus, OH
Laurie Bossory, MD, The Ohio State University Wexner Medical Center, Columbus, OH, Saurav Uppal, MD, Summa Health System, Hudson, OH and Richard Gumina, MD, PhD, The Ohio State University College of Medicine, Columbus, OH
Title
Novel strategies to overcome a challenging mechanical thrombectomy of a saddle pulmonary embolism
Introduction
Pulmonary embolism (PE)/venous thromboembolism is the third most common cardiovascular complication after myocardial infarction and stroke. PEs carry significant morbidity and mortality. Although most patients can be managed with systemic anticoagulation alone, escalation of care can become critical with the development of cardiovascular/respiratory compromise. Systemic and catheter-directed thrombolysis carries significant bleeding risks and contraindications. Catheter-assisted embolectomy offers an alternative option for treatment of critically ill patients.
Clinical Case
42-year-old with a past medical history of prior pulmonary embolisms and factor V Leiden deficiency presented to a neighboring hospital with acute onset shortness of breath, lightheadedness and chest pain while in the bathroom having a bowel movement. Three weeks prior to his presentation, he developed a cough, treated with five days of antibiotics by his primary care physician. His symptoms continued to progress to malaise and loss of taste/smell and was subsequently diagnosed with COVID-19 infection. Symptoms also included right calf pain that started 3 days prior to his presentation. He checked his oxygen saturation at home and found it to be 85%. At his local hospital, he was placed on 4L of oxygen to maintain oxygen saturation >90%. He was also found to have an elevated troponin of 1177 ng/L. Computed tomography for pulmonary embolism (CTPE) showed extensive saddle thromboembolism and evidence of right ventricular strain with enlargement. He was transferred to our hospital for further management. A venous duplex showed extensive residual thrombus in the right common femoral, popliteal, gastrocnemius, posterior tibial and peroneal veins. Given the extensive clot burden and right ventricular strain, the decision was made to proceed with catheter-assisted pulmonary thrombectomy. Moderate thrombus was retrieved with initial passes using the Flowtriever device. During the final aspiration, there was no blood return suggesting a large clot was attached to the distal tip of the catheter. Catheter and sheath were pulled into the distal inferior vena cava (IVC) and angiogram performed confirmed large thrombus attached to the catheter tip. Flowtriever discs were deployed within the proximal IVC, using contralateral venous access, to ensure no clot embolization from the catheter. Flowtriever sheath and device were removed together from the left femoral vein. No thrombus was retrieved from the catheter or sheath. The sheath was readvanced and a repeat angiogram showed large thrombus in the left iliac veins. A Clot triever device was then utilized to successfully retrieve the thrombus via mechanical thrombectomy. Final pulmonary angiogram showed resolution of the saddle embolism. His mean pulmonary pressure improved from 32 mmHg to 22 mmHg post intervention. The patient was transitioned to oral Rivaroxaban and discharged the following day without supplemental oxygen requirements.
Discussion
Catheter-assisted thrombectomy offers a viable and safe option for patients with large proximal thrombus burden with evidence of respiratory or cardiovascular compromise. In this case, we demonstrate an alternative strategy for removing thrombus burden too large for the thrombectomy catheter and strategy to prevent complications of potential distal embolization and intraprocedure recurrent pulmonary emboli.