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Vacuum to the Rescue: Aspiration of a Large Mobile Aortic Arch Thrombus With the AngioVac System Utilizing Transcaval Access
Case Presentation
J INVASIVE CARDIOL 2021;33(9):E756-E757.
Key words: AngioVac System, thrombus aspiration, transesophageal echocardiography
A 55-year-old woman with no medical history presented with left cerebellar stroke after presenting 2 weeks prior for recurrent acute left upper-arm limb ischemia requiring thrombectomy. She takes apixaban and levothyroxine tablets. Extensive work-up revealed a large thrombus in the aortic arch (with a large mobile segment) in close proximity to the left subclavian artery origin (Video 1). A hypercoagulable work-up was negative. After a multidisciplinary meeting, a transcatheter thrombectomy with the AngioVac system (Angiodynamics) was recommended.
The patient’s iliofemoral and subclavian vessel size precluded percutaneous cannulation. We decided to perform transcaval aortic access to facilitate passage of a 26 Fr DrySeal cannula (Gore Medical).
Given the proximity of the thrombus to the left subclavian, bilateral cerebral embolic protection was performed with 2 Sentinel cerebral embolic protection devices (Boston Scientific) (Figure 1). We then obtained transcaval access using standard technique (Figure 2) and a 26 Fr DrySeal sheath was placed across the retroperitoneum into the abdominal aorta. A 17 Fr cannula (Edwards Lifesciences) was placed into the contralateral vein to serve as the AngioVac return cannula. A 180° Gen 3 AngioVac catheter was then prepped in standard fashion and advanced through the 26 Fr DrySeal sheath; it was then engaged with transesophageal echocardiography guidance in the aortic thrombus, and the mobile part was successfully aspirated (Figure 3 and Video 2) with small residual clot that was adherent to the aortic wall (Video 3). The patient was discharged on therapeutic warfarin.
Multiple case reports have been published using the AngioVac system for right-sided clots or vegetations and a few others report AngioVac in the aorta.1,2 Our case is the first to utilize transcaval access for a successful aspiration of the mobile part of a large aortic arch thrombus. Future studies are needed to further define this approach.
Affiliations and Disclosures
From the Center for Structural Heart Disease, Division of Cardiology, Henry Ford Health System, Detroit, Michigan.
Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.
Manuscript accepted April 27, 2021.
The authors report patient consent for the images used herein.
Address for correspondence: Brian O’Neill, MD, Henry Ford Hospital, Center for Structural Heart Disease, 2799 West Grand Blvd, Clara Ford Pavilion, 4th Floor, Detroit, MI, 48202. Email: boneil3@hfhs.org
References
1. Grimm JC, Parsee AM, Brinker JA, et al. Utilization of AngioVac and snare for eradication of a mobile right atrial thrombus. Ann Thorac Surg. 2015;99:698-700.
2. Frisoli TM, Chak-Yu S, Guruswamy JG, Chebl AB, Lee JC, Eng MH. Vacuuming in crowded dangerous spaces aspiration of large ascending aortic thrombus. JACC Case Rep. 2020;2:1979-1983.
