Percutaneous Thrombus Removal in a COVID-19–Infected Patient with Pulmonary Embolism

Abstract

We present a case describing the use of the AngioVac system (AngioDynamics, Inc.) and SENTINEL™ cerebral protection system (SCPS; Boston Scientific) in a patient with COVID-19 who initially presented with a large deep-vein thrombosis of the left lower extremity, complicated by a pulmonary embolism. Although he initially improved with systemic alteplase, he later developed a second large clot diagnosed in transit in the right atrium. Within 12 hours from initial thrombolysis, this large clot wedged across an incidental patent foramen ovale (PFO), the atrial septum, and the cavotricuspid annulus. We emergently performed a percutaneous clot extraction with preemptive placement of the SCPS in anticipation of cardioembolic phenomenon. A large (> 10 cm) clot was extracted without complication, and the patient was discharged home. The combined use of SCPS and AngioVac in this case suggests a potential role for percutaneous treatment of severe and consequential thromboembolic disease, especially in patients with a PFO, and may be considered as an alternative and less-invasive option in patients with COVID-19. While cerebral embolic protection devices are approved for and widely used in transcatheter aortic valve replacement procedures, there is a theoretical benefit for use in percutaneous thrombolectomies as well.

Simultaneous pulmonary embolization and myocardial infarction with ST-segment elevation related to paradoxical embolization: Significance of patent foramen ovale

“…When present, it is necessary to search for the symptoms of paradoxical embolism. Making the diagnosis at an early stage makes it possible to remove the thrombus and close the PFO by car-diac surgery, which constitutes a recommended procedure [5]. In the case of crossed embolism, taking a therapeutic approach (thrombolysis/cardiac surgery) should be individualized depending on the case because there are no direct guidelines for the treatment in such clinical situations [4,5].…”

“…Making the diagnosis at an early stage makes it possible to remove the thrombus and close the PFO by car-diac surgery, which constitutes a recommended procedure [5]. In the case of crossed embolism, taking a therapeutic approach (thrombolysis/cardiac surgery) should be individualized depending on the case because there are no direct guidelines for the treatment in such clinical situations [4,5]. Rescue percutaneous aspiration thrombectomy of the coronary artery has limited effectiveness in the treatment of venous thrombus occlusion due to its size and structure (so-called red thrombus: erythrocyte-rich), as opposed to the well-documented high effectiveness of classic arterial thrombus aspiration in an unstable atherosclerotic plaque (so-called white thrombus: platelet-rich).…”

“…Still, a vast armamentarium of interventional devices is left as a second-line treatment option and recommended mostly when systemic thrombolysis fails or is contraindicated. One of the promising options is the combined use of the AngioVac system (AngioDynamics, Inc., Latham, NY, US) and SENTI-NEL™ cerebral protection system (SCPS; Boston Scientific, Marlborough, MA, US) [5]. This device has a potential role in percutaneous treatment of thrombus in transit, especially in patients with contraindications for thrombolysis and patients who may not be eligible for surgery [5].…”

“…One of the promising options is the combined use of the AngioVac system (AngioDynamics, Inc., Latham, NY, US) and SENTI-NEL™ cerebral protection system (SCPS; Boston Scientific, Marlborough, MA, US) [5]. This device has a potential role in percutaneous treatment of thrombus in transit, especially in patients with contraindications for thrombolysis and patients who may not be eligible for surgery [5]. The presence of PFO poses a risk of crossed embolism in patients with deep-vein thrombosis and PE.…”

“…The presence of PFO poses a risk of crossed embolism in patients with deep-vein thrombosis and PE. This is an important argument for prophylactic PFO closure or for administering chronic anticoagulant therapy [2,5]. However, currently, PFO occlusion in patients with suspicion of cerebral or noncerebral embolism is neither clearly nor definitely established.…”