ICE-Guided Percutaneous Thrombectomy of Thrombus-in-Transit With Impending Paradoxical Embolism Through PFO and Pulmonary Embolism

Figures

• 

  Visual Summary. Echocardiographic Images and Aspirated Thrombi (Video Summary) Findings on intracardiac echocardiography include (A) a thrombus-in-transit, (B) an impending paradoxical embolism, and (C) the position of the AlphaVac funnel tip in the right atrium. (D) The extracted thrombi postprocedure. Ao = aorta; IAS = interatrial septum; LA = left atrium; RA = right atrium; TV = tricuspid valve.

• 

  Figure 1. Bedside Echocardiography, Apical 4-Chamber View (A) An echogenic, serpentine, and mobile thrombus is visible in the right atrium, attached to the interatrial septum. (B) The thrombus traverses into the left atrium through the interatrial septum. LA = left atrium; LV = left ventricle; TV = tricuspid valve.

• 

  Figure 2. Intracardiac Echocardiography, Biplane Views (A) A large, serpentine thrombus is visualized within the right atrium. (B) The thrombus is seen traversing the interatrial septum from the right atrium to the left atrium through a patent foramen ovale. Ao = aorta; IAS = interatrial septum; LA = left atrium; RA = right atrium; TV = tricuspid valve.

• 

  Figure 3. Fluoroscopic Visualization of Device Placement During the Procedure A Sentinel cerebral embolic protection device was positioned with its proximal basket in the brachiocephalic artery and its distal basket in the proximal left common carotid artery. An 8.0 × 40 mm Armada balloon was positioned at the proximal left subclavian artery as a blocking balloon.

• 

  Figure 4. Intracardiac Echocardiography, Biplane View, During Mechanical Thrombectomy The AlphaVac funnel tip is positioned in the right atrium for thrombus aspiration under real-time ICE guidance. ICE = intracardiac echocardiography; RV = right ventricle.

• 

  Figure 5. Intracardiac Echocardiography, Biplane View, After Successful Mechanical Thrombectomy (A) The right atrium is clear with no residual thrombus. (B) No residual thrombus is visible across the PFO. LA = left atrium; PFO = patent foramen ovale; TV = tricuspid valve.

• 

  Figure 6. Pulmonary Angiography Before and After Mechanical Thrombectomy (A and C) Baseline angiograms showing thrombi within the distal (A) right and (C) left main pulmonary arteries. (B and D) Post-thrombectomy angiograms showing clearance of the thrombi.

• 

  Figure 7. Specimen of the Thrombi Retrieved During Mechanical Thrombectomy The specimen comprises the large, serpentine thrombus-in-transit that was lodged across the interatrial septum, along with the thrombi aspirated from the right and left main pulmonary arteries.