Percutaneous Aspiration of Ascending Aortic Mural Thrombus Under Intra-Aortic Intracardiac Echocardiographic Guidance.

BACKGROUND

Ascending aortic mural thrombus can be highly mobile and cause systemic embolization, even without aneurysm or advanced atherosclerosis.

CASE SUMMARY: A 57-year-old man with coronary artery disease, prior coronary artery bypass grafting, chronic obstructive pulmonary disease, and recent orthopedic surgery presented with chest tightness and cough. Computed tomography angiography revealed a multilobulated ascending aortic mural thrombus measuring 26 × 11 mm. Despite heparin therapy, he developed acute right internal carotid artery occlusion requiring thrombectomy. Follow-up imaging showed persistent mobile thrombi, and transesophageal echocardiography (TEE) was limited. Percutaneous debulking using the AngioVac system with intracardiac echocardiography (ICE) guidance successfully removed the thrombus without complications.

DISCUSSION: This case demonstrates a novel percutaneous approach for ascending aortic thrombus removal using intra-aortic ICE to overcome TEE blind spots, allowing safe, targeted aspirations.

TAKE-HOME MESSAGE: TEE has blind spots in the proximal ascending aorta. ICE provides real-time guidance, facilitating safer real-time procedural visualization and AngioVac thrombus aspirations.