Percutaneous Thrombectomy of a Thrombus in Transit Through a Patent Foramen Ovale: A Novel Approach.

BACKGROUND: Transcatheter vacuum-assisted mass extraction is a safe alternative to surgical thrombectomy in high-risk patients, although experience with left-sided intracardiac material is limited. CASE PRESENTATION: A 19-year-old man with newly diagnosed Hodgkin lymphoma developed airway compromise, cardiac tamponade, massive pulmonary embolism, and cardiogenic shock requiring venoarterial-venous extracorporeal membrane oxygenation. Echocardiography showed a mobile biatrial thrombus traversing a patent foramen ovale. Because of prohibitive surgical risk, he underwent AngioVac (AngioDynamics, Inc) thrombectomy with bilateral cerebral embolic protection, transient aortic flow arrest, and septal occluder-mediated thrombus entrapment, with hemodynamic stabilization and no stroke on follow-up imaging. DISCUSSION: In a patient with biatrial thrombus and prohibitive surgical risk, percutaneous AngioVac thrombectomy provided a feasible alternative to open thrombectomy. Cerebral protection, transient interruption of antegrade aortic flow during left atrial aspiration, and septal occluder-mediated thrombus containment addressed the major risk of systemic embolization. TAKE-HOME MESSAGES: Biatrial thrombus traversing a patent foramen ovale requires treatment planning that accounts for both pulmonary and systemic embolic risk. In selected inoperable patients, cerebral protection, temporary aortic flow arrest, vacuum-assisted aspiration, and septal occluder-mediated thrombus entrapment can be considered within a multidisciplinary strategy.