Simultaneous saddle pulmonary embolism and right atrial thrombus managed with ICE-guided dual suction Thrombectomy

Abstract Saddle pulmonary embolism (PE) complicated by right atrial thrombus in transit is an infrequent but highly lethal condition. Standard treatments such as systemic thrombolysis or surgical embolectomy carry significant risks, particularly in elderly or comorbid patients. We describe the case of a 76-year-old man with spina bifida, cauda equina syndrome, chronic immobility, and multiple comorbidities who presented in shock. Imaging revealed a large saddle PE with mobile right atrial thrombus and right ventricular strain. Given prohibitive surgical risk and contraindications to thrombolysis due to recent spinal infection and acute kidney injury, and high bleeding risk, he underwent percutaneous suction thrombectomy using the FlowTriever system. Large thrombus burden was successfully removed from both the right pulmonary artery and right atrium, with restoration of flow and hemodynamic stabilization. He was transitioned to long-term anticoagulation and discharged in stable condition. This case highlights the role of dual-site suction thrombectomy as a life-saving option when conventional therapies are contraindicated.