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.