024 - Clot In Transit: Feasibility of Mechanical Thrombectomy
rehan quadri, MD – Attending, Interventional Radiology, UT Southwestern Medical Center
Purpose: CIT is a high-risk mobile clot found in peri-cardiac/intra-cardiac locations. We examine a cohort of patients undergoing Inari device mechanical thrombectomy for known extensive thrombus as an alternative to V-V ECMO and surgical intervention. Rapid onset of cardiopulmonary symptoms triggers clinical diagnosis of Clot-In-Transit (CIT), generally in the setting of IVC, SVC and PE/VTE thrombus burden. In symptomatic cases, patients can experience traditional PE symptoms, however; depending on embolization, concomitant renal failure, pelvic congestion, SVC, or Budd-Chiari syndrome may ensue.
Material and Methods: An Institutional review board was obtained for retrospective analysis of patients with CIT over the past two years from our institution. All patients with high-risk mobile clots, with intra-cardiac burden or clot in transit, were included. A total of 13 patients, age range from 17-71 underwent mechanical thrombectomy with Inari aspiration devices for CIT. All patients demonstrated CIT with peri-cardiac or intracardiac thrombus on pre-procedure or intra-procedural angiography/intracardiac echocardiography. All of these patients were excluded from surgical intervention and were considered high risk for V-V ECMO initiation. Clinical follow-up for all patients was conducted.
Results: 13 patients underwent successful mechanical aspiration thrombectomy with inari devices under general anesthesia. No patient required V-V ECMO in their post-procedure clinical course with no documented clinical complications from the mechanical thrombectomy session. Pathological analysis of clot reveals no evidence of neoplastic process, demonstrating bland thrombus as the primary culprit in all cases. All cases were performed urgently including imaging and consultation. 12/13 patients demonstrated improved functional status and outcomes, with one death from pre-existing neoplastic disease burden.
Conclusions: Mechanical thrombectomy offers a safe and reliable modality for clot-in-transit patients without neccisstating V-V ECMO cannulation. Previous literature demonstrates the need for emergent V-V ECMO intervention; however, given our single-center experience with general anesthesia, we report the excellent feasibility of this method, including improved functional clinical status at follow-up. Our experience offers a paradigm shift for these critically-ill patients, including an extended window of pre-procedural work-up to enhance the success of clot removal.