Introduction
Alternative therapies to massive or submassive pulmonary embolism (PE)
include surgical embolectomy, systemic thrombolysis, and endovascular
catheter directed lysis. In patients with contraindication to
thrombolysis, mechanical thrombectomy can restore pulmonary circulation
and avoid cardiogenic shock. Surgical thrombectomy is a tool for
patients with rapid hemodynamic deterioration, clot-in-transit within
the right heart, or when an underlying right-to-left shunt is present
(1). The 2011 American Heart Association guidelines for surgical
embolectomy included patients with massive PE who exhibited
contraindications to receive fibrinolysis, or patients who remain
unstable after thrombolysis (2). Reported complications of the surgical
approach included rethrombosis risk, postoperative bleeding, cardiac
tamponade, and sternal wound infection (3).
The AngioVac device (Angiodynamics, Latham, NY USA), offers an important
alternative to surgical thrombectomy for right heart thrombus (RiHT)
with a success rate reported up to 87% in a literature review including
28 patients (4). However, the reported success for pulmonary embolism
(PE) was significantly lower at 12.5%. The complication rate was up to
12% (Total of 56 patients treated) including fatal retroperitoneal
hemorrhage or right ventricular perforation (4, 5). A recent case report
described the use of FlowTriever under transthoracic echocardiography
(TTE) guidance for mechanical thrombectomy of right intra-atrial
thrombus with instantaneous and marked decrease in clot burden and
pulmonary reperfusion and hemodynamic recovery. It also described the
benefit of less blood loss than the AngioJet and Penumbra systems (6).
We report the use of FlowTriever device as a modality to treat clot in
transit and massive PE when thrombolysis is contraindicated.