LAUSR

Learning Objectives: We present a case of percutaneous thrombectomy of a large in-transit right atrial (RA) thrombus. Methods: A 53 year-old male presented to the trauma bay via police drop-off. On primary survey he was awake, alert, moving all extremities, vital signs stable. Exposure noted two torso gunshot wounds: one to the right upper quadrant and one in the back. He rapidly became combative, confused and hypotensive. He received packed red blood cells (PRBC), 1 gram of tranexamic acid (TXA) and was taken to the operating room. Laparotomy revealed destructive injuries to the right kidney and right lobe of the liver, necessitating nephrectomy and non-anatomic liver resection. Intraoperatively, a REBOA device was placed given ongoing bleeding and hemodynamic instability. His abdomen was left open and he was transferred to the ICU for ongoing resuscitation. Total blood loss was 5.5 liters, and he received 15 units of PRBC, 12 units of fresh frozen plasma, 4 packs of platelets, and 1350 ml of autologous blood. A bedside echocardiogram (ECHO) was performed on post-operative day 2, demonstrating a large right atrial clot. Subsequent transesophageal ECHO (TEE) showed the clot originating at the inferior vena cava-right atrial junction with prolapse through the tricuspid valve. Systemic anticoagulation was initiated. Cardiac surgical consultation deferred treatment to interventional cardiology, who utilized the endovascular AngioVac device to remove the entire mobile in-transit thrombus under TEE and fluoroscopic guidance. Two venous cannulas were placed to allow for insertion of the device and return of blood. A flow rate of 4 liters was required to aspirate the clot. There was no evidence of distal embolization. The patient had a prolonged but successful recovery. Results: Right heart thrombi in the absence of structural heart disease, atrial fibrillation, or intracardiac catheter are usually intransit, migrating from the venous system, and potentially lead to life threatening pulmonary embolism. Poly-trauma is a known risk factor for thrombosis, and the administration of TXA may have further contributed to the patient’s prothrombotic state. Preferred therapy for in-transit thrombi is controversial and includes systemic anticoagulation, tPA and operative removal. The current case demonstrates successful catheter-directed removal without complication.