Abstract 15294: Right Atrial Thrombus Extraction Through Angiovac - A Challenge Based on Chronicity

Abstract

Case Presentation: 23-year-old woman with right ovarian dysgerminoma, treated with debulking surgery and bleomycin, etoposide, and platinum, found to have a right atrial (RA) mass on post-chemotherapy surveillance CT and referred to the cardiology clinic. Her vitals were stable, lungs were clear to auscultation, RRR without murmurs, no JVD or LE edema. On labs, hgb:11g/dL and LDH:283 units/L(135 to 214 units/L). A transthoracic echocardiogram (TTE) and a cardiac MRI revealed a mass of RA at the junction of inferior vena cava (IVC) entry into RA, measuring 3x1.3 cm in the 2-chamber view and 2.4x1.8 cm in the 4-chamber view (Fig A,B) with prolapse into the right ventricle (RV) in diastole. Based on cardiac MRI’s short and long inversion time imaging characteristics, thrombus was the most likely diagnosis (Fig C). Shared decision-making with the patient included options: 1) open heart surgery for removal; 2) interventional aspiration thrombectomy; or 3) conservative treatment with anticoagulation (AC). After six weeks of AC with enoxaparin, TTE revealed a RA thrombus of the same size as previously (2.8x1.2 cm). Given the lack of improvement, she agreed to an invasive procedure to remove the mass using an AngioVac aspiration system (AngioDynamics, Latham, NY). The AngioVac cannula maneuvered in the RA under fluoroscopic and TEE guidance to capture the RA mass. However, the mass broke into two pieces, one piece still attached to the RA and the other piece lodged in the AngioVac cannula (Fig D,E). She remained hemodynamically stable after the procedure. The pathology of the RA mass revealed an organized thrombus (Fig F). She had no complaints on follow-up in the clinic and continued on AC for 6 months. Discussion: Percutaneous aspiration thrombectomy using the AngioVac system has become a novel option for removing commonly encountered intravascular material, such as fresh thrombi or emboli in the RA, RV, SVA, IVC, and the iliofemoral vein, but may be complicated in old thrombi.