Novel use of SpiderFX embolic protection system for mechanical thrombectomy in an infant with catheter-associated thrombosis
Presenter
Danielle D Strah, MD, Rady Children's Hospital, San Diego, CA
Danielle Strah1, Danielle D Strah, MD2, Stephen Dalby, M.D.3 and Henri Justino, M.D., FSCAI2, (1)Rady Children's Hospital/UC San Diego, San Diego, CA, (2)Rady Children's Hospital, San Diego, CA, (3)Arkansas Children's Hospital, Little Rock, AR
Title
Novel use of SpiderFX embolic protection system for mechanical thrombectomy in an infant with catheter-associated thrombosis
Introduction
Large and mobile intracardiac clots pose significant risk of morbidity and mortality due to embolization. Options for removal of intracardiac clots in small children are limited by need for large sheaths and by potential for major blood loss during thrombectomy. We present an infant with a large pedunculated right atrial thrombus and large atrial septal defect (ASD) with concern for potential systemic embolization who underwent successful catheter-based thrombectomy using an embolic protection system.
Clinical Case
A 3-month-old (4.4 kg) infant with history of repaired congenital diaphragmatic hernia underwent routine echocardiogram to reassess a known large ASD. Incidentally, a large thrombus was found along the course of a previous central venous line, extending from the left innominate vein to the right atrium, and adjacent to a large ASD, raising concern for possible systemic embolization.
To minimize the risk of systemic embolization during thrombectomy, temporary occlusion of the ASD was performed with a balloon via the femoral venous access. A 7 mm SpiderFX embolic protection device was advanced through a 4-Fr sheath in the right internal jugular vein, and used to remove the large, pedunculated portion of the thrombus in the right atrium. Due to large thrombus size, it was unable to be removed through the sheath, so the sheath and basket were removed together. On echocardiogram, residual thrombus remained in the left innominate vein and superior vena cava with significant flow gradient noted. Attempts were made to perform aspiration thrombectomy with a MP1 guiding catheter directed at the clot; however, this only resulted in extraction of a small piece of thrombus. Finally, a 5-Fr sheath was placed in the left internal jugular vein, and the SpiderFX system was used to successfully remove the remaining thrombus. Angiography and echocardiogram demonstrated no residual thrombus and no gradient. Total blood loss was 15 cc (12 cc during the ineffective aspiration thrombectomy).
Discussion
We present the novel use of a SpiderFX embolic protection system for percutaneous thrombectomy, which resulted in successful thrombus retrieval with minimal blood loss. Large mobile intracardiac clots pose a significant risk of massive pulmonary embolism, and in the presence of a large ASD, this portends the additional risk of systemic embolization. Current thrombectomy systems have limited utility in infants both due to their large sheath size, and the attendant risk of major blood loss. This case highlights the use of an embolic protection device to successfully extract a large thrombus in a small infant with use of small sheaths and with very limited blood loss.