Thrombo-embolectomy in the Superior Vena Cava and Right Atrium using Angio-Jet and Balloon Occlusion

- Operator : Tommy Ng

Thrombo-embolectomy in the Superior Vena Cava and Right Atrium using Angio-Jet and Balloon Occlusion

- Operator: Tommy Ng, MD

Clinical Characteristics

A 79-year old female with severe coronary artery disease underwent bypass surgery. However, she showed unstable postoperative hemodynamic status, requiring the prolonged support of intra-aortic balloon pump and continuous intravenous heparin infusion. She also received a Swan-Ganz catheter placement for monitoring hemodynamic status via right internal jugular vein. On the 7th postoperative day, she was found to have the thrombus in the left atrium and thrombus formation along the Swan-Ganz catheter. Unfortunately, she developed a heparin-induced thrombocytopenia and concomitant fever. Therefore, heparin was switched to argotroban. Trans-esophageal echocardiogram (TEE) revealed a large long thrombus attached to the catheter extending from superior vena cava to upper portion of the right atrium (Figure 1).

Procedure

To avoid thrombus migration, a valvuloplasty balloon of 25mm in diameter was inserted through right femoral vein and advanced into high right atrium (Figure 2). To move the distal end of thrombus into superior vena cava, the Swan-Ganz catheter was partially withdrawn (Figure 3), and the balloon was fully inflated at the junction of superior vena cava and right atrium (Figure 4). Right median basilic vein isolated and 8 French guiding catheter was advanced into right subclavian vein and angiogram was obtained to assess the location and the size of thrombus. A TEE transducer was placed and used to monitor the entire procedure.
A rheolytic Angio-Jet was inserted into the previously placed guiding catheter. While the system was being activated, Angio-Jet catheter was passed several times and successful removal of visible thrombus was shown on TEE (Figure 5, Figure 6). After the deflation of balloon and the removal of Swan-Ganz catheter, TEE revealed several free floating emboli in the right atrial chamber which required another activation of Angio-Jet system in the right atrial chamber. All emboli could be removed and TEE revealed no more evidence of thromboemboli in the right heart and pulmonary arteries (Figure 7, Figure 8). After procedure, patient was discharged with any other events.
||

Leave a comment

Sign in to leave a comment.