ICE-Guided Percutaneous Thrombectomy of Thrombus-in-Transit With Impending Paradoxical Embolism Through PFO and Pulmonary Embolism.

OBJECTIVE

Impending paradoxical embolism (IPE), defined as thrombus entrapped across a patent foramen ovale, is rare in acute pulmonary embolism (PE) and is associated with high mortality. We present to our knowledge the first successful intracardiac echocardiography (ICE)-guided mechanical thrombectomy for simultaneous treatment of right ventricular thrombus-in-transit (TIT), IPE, and high-risk PE.

KEY STEPS: ICE was used to locate the mobile TIT straddling the patent foramen ovale. For embolic protection, a Sentinel cerebral protection system was deployed via the right radial artery, while a blocking balloon positioned in the left subclavian artery. A 24-F femoral venous access enabled advancement of the AlphaVac F1885 system into the right atrium. Under ICE guidance, aspiration evacuated the TIT and IPE, followed by catheter-based pulmonary thrombectomy.

POTENTIAL PITFALLS: Percutaneous thrombectomy is feasible for patients unsuitable for surgery or thrombolysis but carries a risk of paradoxical embolization. Embolic protection is therefore essential.

TAKE-HOME MESSAGE: ICE-guided AlphaVac thrombectomy of TIT, IPE, and PE is feasible in high-risk patients.