LAUSR

To the Editor, The AngioVac (AngioDynamics, Latham, New York) system is a vacuum-assisted venous aspiration system specifically designed for the removal of large clots or emboli that utilizes an extracorporeal veno-venous bypass system to avoid risks of excessive blood loss. Prior reports have demonstrated the safety and efficacy of the AngioVac system for removal of large thrombus burden [1–4]. The purpose of this letter is to illustrate the utility of transesophageal echocardiogram (TEE) and transabdominal ultrasound (TUS) for guidance of the AngioVac cannula in removal of IVC and right atrial thrombus. A 47-year-old man with nonischemic cardiomyopathy of unknown etiology, severe heart failure with an ejection fraction of 10–15%, atrial fibrillation and history of embolic stroke was transferred from outside institution with decompensated cardiogenic shock. The patient was placed on venoarterial extracorporeal membrane oxygenation (ECMO). Subsequently, the patient underwent left ventricular assist device placement while awaiting a heart transplant and was taken off ECMO after a total of 5 days. On a follow-up echocardiogram, a large, elongated, floating thrombus was seen extending from the IVC into the right atrium, measuring approximately 16 9 1 cm. Interventional radiology was consulted for removal of thrombus and the decision was made to use AngioVac device for aspiration of clot based on its size and location. The procedure was performed in an operating room with cardiothoracic surgery team on call. After induction of anesthesia, TEE was performed by the anesthesiology team, which clearly demonstrated the upper extent of the floating thrombus in the intrahepatic IVC extending into the right atrium (Fig. 1). TUS was also performed by the procedure team, which showed the inferior extent of the floating thrombus in the suprarenal portion of the IVC. Next, a 22Fr AngioVac suction cannula was inserted via the right internal jugular vein. A 19 Fr reinfusion cannula was introduced into the inferior vena cava via the right common femoral vein. Initially, the AngioVac suction cannula was positioned at the atriocaval junction under fluoroscopy, based on anatomical landmarks. After connecting to the extracorporeal circuit and inflating the balloon, suction was performed under fluoroscopy, which did not yield any clot and resulted in aspiration of significant amount of blood. At this point, TEE was used to visualize the AngioVac cannula tip. Under direct TEE visualization, the AngioVac cannula was then maneuvered and placed precisely above the thrombus (Fig. 2A–C). Repeat suction successfully aspirated the clot which was immediately seen inside the filter (Fig. 3A). Subsequent TEE and TUS images of the inferior vena cava following the aspiration showed complete absence of the previously identified clot (Fig. 2D). Both femoral and jugular catheters were removed, and hemostasis was achieved using a combination of pursestring suture and manual compression. The patient remained hemodynamically stable throughout the procedure, with no acute change in his condition in the postprocedure setting. & Kush S. Shah [email protected]