Clot In Transit Research Articles

Comparing upfront catheter-based thrombectomy with alternative treatment strategies for clot-in-transit.

Clot-in-transit (CIT) is associated with high mortality, and optimal treatment strategies remain uncertain. This study compares the efficacy of catheter-based thrombectomy (CBT) with other treatments for CIT, including anticoagulation, systemic thrombolytic (ST) therapy, and surgical thrombectomy. We conducted a retrospective analysis of patients with CIT documented on echocardiography between January 2020 and May 2024, managed with urgent upfront CBT. We compared the all-cause mortality rates of the CBT cohort to performance goal rates for anticoagulation, systemic thrombolysis (ST), and surgical thrombectomy from a published meta-analysis. Our cohort included 26 patients who underwent CBT (mean age 59.3 ± 17.9 years, 42.3% women, 57.7% Black). Compared to 463 patients from the meta-analysis receiving alternative treatments, the CBT group's short-term mortality was significantly lower (7.7% vs 32.4% for anticoagulation, 13.8% for ST, and 23.2% for surgical thrombectomy). CBT demonstrated noninferiority to anticoagulation (P < .001), ST (P = .031) and surgical thrombectomy (P < .001), and was superior to anticoagulation (P = .0056) and surgical thrombectomy (P = .036). This study suggests CBT is a promising treatment for CIT. Further prospective studies are warranted to validate these findings.

Outcomes with treatment interventions for clot-in-transit in patients with pulmonary embolism: a meta-analysis.

Clot-in-transit (CIT) in patients with pulmonary embolism (PE) has been associated with a high mortality rate and poor prognosis. The aim of this study was to evaluate the pooled efficacy of each of the 4 interventions (anticoagulation [AC] alone, systemic thrombolytic [ST] therapy, surgical thrombectomy, and catheter-based thrombectomy [CBT]) using mortality as the primary outcome. A time limited search until March 28, 2024 was conducted using PubMed (National Institutes of Health) and EMBASE (Elsevier) databases. Thirteen studies (6 retrospective, 4 non-randomized prospective, and 3 pooled studies of case-reports) were included in the calculation of weighted proportion of mortality, including a total of 492 patients with CIT and PE with a mean age of 60.6 years; 50.1% were males. ST was the most frequently used treatment intervention (38.2%), followed by surgical thrombectomy (33.8%), AC alone (22.6%), and CBT (5.9%). The unweighted mortality was highest with AC alone 32.4% (36/111), followed by surgical thrombectomy 23.2% (38/164), CBT 20.7% (6/29), and ST 13.8% (26/188). The weighted mortality for AC alone was 35% (95% CI, 21% to 49%; 12 studies), surgical thrombectomy was 31% (95% CI, 16% to 47%; 12 studies), CBT was 20% (95% CI, 6% to 34%; 3 studies), and ST was 12% (95% CI, 5% to 19%; 12 studies). In this meta-analysis of patients with CIT and PE, the highest mortality was observed with AC alone, followed by surgical thrombectomy, CBT, and ST therapy. However, there remains a need for randomized clinical trial data to determine the best treatment.

Abstract 12644: FlowTriever Percutaneous Aspiration Thrombectomy: A Promising Approach to Catch a (Throm)Bus In-Transit

Introduction: Clot-in-transit (CIT) is a life-threatening emergency that occurs in about 25,000 patients annually and is associated with high mortality due to rapid cardiopulmonary collapse. This is a case of right atrial (RA) CIT extending from existing IVC filter in a patient with pulmonary embolism (PE) who underwent successful FlowTriever® catheter-based thrombectomy. Description of Case: A 60-year-old male presented with progressively worsening dyspnea on exertion, generalized weakness and fatigue, intermittent chest pain, and right leg pain with immobility for several weeks. He had a history of deep vein thrombosis (DVT), PE in 2008 treated with 18-month of warfarin. IVC filter was placed at that time for unclear indication. His initial labs showed elevated troponin-I of 34 ng/mL and NT pro-BNP of 3542 pg/mL, atrial flutter with 2:1 conduction, incomplete right bundle branch block, and old inferior infarct on ECG. Imaging revealed an extensive bilateral PE with right ventricle (RV) to left ventricle (LV) ratio of 2.3. Transthoracic echocardiogram (TTE) showed global LV dysfunction with ejection fraction of 44%, RV strain, dilated IVC, and an 8.7-cm mobile CIT in IVC extending into RA. Despite being treated with Heparin infusion, patient remained persistently tachycardic and dyspneic. Given his clinical stagnation due to CIT and submassive PE, he underwent an invasive TTE-guided percutaneous IVC and pulmonary arterial thrombectomy using Inari FlowTriever® catheter. Repeated TTE showed complete resolution of atrial thrombus. There was improvement in pulmonary arterial pressure and symptoms immediately post thrombectomy, but atrial flutter persisted. He was eventually discharged the following day with betablocker and life-long duration of anticoagulation. At follow up, he had complete resolution of symptoms and normal sinus rhythm on ECG. Discussion: Although surgical embolectomy is considered first-line therapy, percutaneous thrombectomy should be considered early for CIT to prevent of cardiopulmonary deterioration and shorter hospital course. FlowTriever® is the first device not requiring a cardiopulmonary bypass circuit to be FDA cleared for RA CIT, particularly benefiting patients who are poor surgical candidates.

Abstract 14891: Time to Therapeutic Range for Patients With Acute Pulmonary Embolism Undergoing Mechanical Thrombectomy

Introduction: Anticoagulation therapy is the mainstay for the management of patients with acute pulmonary embolism (PE) and achieving a timely time to therapeutic range (TTR) is important. We sought to determine the TTR in patients with acute PE referred for mechanical thrombectomy (MT) and the proportion of patients with therapeutic activated clotting time (ACT) at the time of MT. Methods: This single center retrospective study included all patients who underwent percutaneous MT at a large academic public hospital from January 2020 through April 2023. Therapeutic anticoagulation was defined as an ACT &gt;200 seconds or if the patient received enoxaparin within 6 hours prior to MT. Results: A total of 63 patients (average age 58 years, 43% female) with intermediate or high-risk PE were included in the analysis. The median time from the diagnosis of PE or clot-in-transit (CIT) to MT was 15 (IQR 6.1-23.2) hours. Fifteen patients (23.8%) were initiated on enoxaparin at the diagnosis of acute PE or CIT. Among these patients, 5 (7.9%) were on enoxaparin only and 10 (15.9%) patients were initiated on enoxaparin and then transitioned to a heparin infusion prior to MT. One patient was initiated on argatroban, while the remaining 47 patients were initiated on a heparin infusion at time of diagnosis (77.6% received heparin bolus). In patients who received a heparin infusion, the median ACT in the cath lab was 134 (IQR 118-159) seconds. Only a total of 9/63 (14.3%) were therapeutic by ACT at the time of MT or received therapeutic enoxaparin within 6 hours of MT. Excluding patients who received enoxaparin initially, 34/48 (70.8%) patients reached a therapeutic anti-Xa or partial thromboplastin time (PTT) levels. The median time to reach a therapeutic anti-Xa or aPTT was 5.6 (IQR 3.3-8.2) hours (Figure). Conclusion: In patients with acute PE referred for MT, only a minority of patients had therapeutic ACT prior to mechanical thrombectomy.

Mechanical Thrombectomy for a Clot in Transit With Adherence to the Tricuspid Valve

Mechanical Thrombectomy for a Clot in Transit With Adherence to the Tricuspid Valve

Tumor thrombosis in transit

Hepatocellular Carcinoma (HCC) is a poor prognosis cancer of liver which could be associated with venous thrombo-emboli but cardiovascular metastasis is rare; Here we present a case of HCC with tumor thrombosis and clot in transit who managed conservatively with anticoagulation.

A Clot in Transit: A Cause of Death or a Bystander?

The clot in transit is a rare manifestation of thromboembolic disease occurring usually in the setting of PE and frequently associated with poor outcomes. The best therapeutic option is not well established. We describe a series of 35 patients diagnosed with clots in transit including their therapeutic interventions and outcome between the period January 2016 to December 2020. a retrospective chart review of all patients with an Echocardiogram showing thrombi in the right heart chambers including patients with thrombus in the presence of central lines or other devices. We exclude patients where masses were described as tumors or vegetation and masses in the presence of bacteremia. There were 35 patients with echocardiographic evidence of a thrombus in the right heart chambers. In 12 of those patients, the thrombus was related to an intracardiac catheter. 37.1% of CT chest was done along with Echocardiogram and showed a concomitant PE in 77%. On echocardiogram, 66% of the thrombi were mobile. RV strain was present in 17% while abnormal RVSP (>30 mmHg) was present in 74%. Respiratory support was required in 37.1% and only 17% required inotropic support. There was a total or partial resolution in 80% those who had repeated echocardiogram after four weeks of therapy. Heparin was started in the majority of patients (74%). Warfarin was the most frequently used follow-up anti-coagulant in 51.4%. The mortality rate was significantly higher in those patients with RVSP >50, UFH group, O2 or inotropic support. 26% of patients died within the first 28 days after the diagnosis, while first 7 days mortality was 6% only. a clot in transit in our study was not directly associated with poor outcomes in the first week of therapy, UFH is still the most frequently used initial method to treat clots in transit. However, only 26% had a total resolution of clot within 4 weeks of treatment.

Clinical characteristics and treatment of patients with central pulmonary embolism and right heart thrombus.

Right heart thrombus (RHT), also known as clot in transit, is an uncommon finding in pulmonary embolism (PE) that is associated with increased inpatient mortality. To date, there is no consensus on the management of RHT. Therefore, we aim to describe the clinical features, treatments, and outcomes of patients with simultaneous RHT and PE. This is a retrospective, cross-sectional, and single-center study of hospitalized patients with central PE who had RHT visualized on transthoracic echocardiography (TTE) from January 2012 to May 2022. We use descriptive statistics to describe their clinical features, treatments, and outcomes, including mechanical ventilation, major bleeding, inpatient mortality, length of hospital stay, and recurrent PE on follow-up. Of 433 patients with central PE who underwent TTE, nine patients (2%) had RHT. The median age was 63 years (range 29-87), most were African American (6/9), and females (5/9). All patients had evidence of RV dysfunction and received therapeutic anticoagulation. Eight patients received RHT-directed interventions, including systemic thrombolysis (2/9), catheter-directed suction embolectomy (4/9), and surgical embolectomy (2/9). Regarding outcomes, 4/9 patients were hemodynamically unstable, 8/9 were hypoxemic, and 2/9 were mechanically ventilated. The median length of hospital stay was six days (range 1-16). One patient died during hospital admission, and two patients had recurrent PE. We described the different therapeutic approaches and outcomes of patients with RHT treated in our institution. Our study adds valuable information to the literature, as there is no consensus on the treatment of RHT. Right heart thrombus (RHT) was a rare finding in central pulmonary embolism. Most patients with RHT had evidence of RV dysfunction and pulmonary hypertension. Most patients received RHT-directed therapies in addition to therapeutic anticoagulation.

Successful aspiration of an iatrogenic clot in transit secondary to a failed mechanical thrombectomy in pulmonary embolism.

A 68-year-old female presented with an intermediate-high-risk bilateral pulmonary embolism (PE) (Panel A) with a severely dilated right ventricle (Panel B). Ultrasound of both femoral veins was normal. Thrombolysis was not performed owing to recent history of gastrointestinal bleeding. The PE team decided to perform a percutaneous mechanical thrombectomy (MT) using the FlowTriever (FT) system (Inari Medical, Irvine, CA, USA). After the first procedure, a large thrombus was obtained from the right pulmonary artery (Panels C–E and Supplementary Video 1); however, we failed to extract any thrombus from the left pulmonary artery (LPA) with both the 24 and 16 Fr catheters, due to tortuosity and poor wire support, with non-sustained ventricular tachycardia. A transthoracic echocardiogram (TTE) and a subsequent transoesophageal echocardiography revealed the presence of a massive clot attached to the tricuspid valve, with severe tricuspid regurgitation (Panels F and G and Supplementary Video 2) that was not present in baseline TTE. Considering it was an iatrogenic event due to a ‘lollipop thrombus’, and the risk of re-embolization, a further MT procedure was performed, with TTE guidance, with the successful retrieval of the clot in transit (Panels H and I), and the remaining LPA thrombi (Panels J–L, Supplementary Video 3).

Massive Pulmonary Thromboembolism with Clot-in Transit in a Patient with Acute Aortic Dissection and Hemothorax- a Clinician's Dilemma

Acute aortic dissection with hemothorax is an uncommon presentation associated with high mortality and morbidity. They are at increased risk of venous thromboembolism. Massive pulmonary embolism with large clot-in transit has not been previously reported, and its management is not clear.

CLOT IN TRANSIT: THE ROLE OF POINT-OF-CARE ULTRASOUND IN EARLY DIAGNOSIS AND IMPROVED OUTCOMES

CLOT IN TRANSIT: THE ROLE OF POINT-OF-CARE ULTRASOUND IN EARLY DIAGNOSIS AND IMPROVED OUTCOMES

OUTCOMES FROM CATHETER-DIRECTED EMBOLECTOMY FOR INTERMEDIATE-RISK AND HIGH-RISK PULMONARY EMBOLISM

OUTCOMES FROM CATHETER-DIRECTED EMBOLECTOMY FOR INTERMEDIATE-RISK AND HIGH-RISK PULMONARY EMBOLISM

A RARE CASE OF THROMBUS IN TRANSIT MIGRATION TO THE MAIN PULMONARY ARTERY IN A PATIENT WITH SUBMASSIVE PULMONARY EMBOLISM

A RARE CASE OF THROMBUS IN TRANSIT MIGRATION TO THE MAIN PULMONARY ARTERY IN A PATIENT WITH SUBMASSIVE PULMONARY EMBOLISM

OUTCOMES FROM CATHETER-DIRECTED EMBOLECTOMY VERSUS SURGICAL PULMONARY EMBOLECTOMY FOR PATIENTS WITH ACUTE PE

OUTCOMES FROM CATHETER-DIRECTED EMBOLECTOMY VERSUS SURGICAL PULMONARY EMBOLECTOMY FOR PATIENTS WITH ACUTE PE

A Proposed Approach for the Management of Clot-in-Transit.

Clot-in-transit (CIT) is defined as a mobile echogenic material in the right atrium or ventricle as observed on ultrasound. A right heart free-floating thrombus is unusual when there is no structural disease of the heart or atrial fibrillation. Cardiopulmonary collapse and quick death can come from CIT, which occurs when a blood clot moves from the heart to the lungs. There are some clinical case reports of a large volume thrombus that was freely floating in the right heart in an asymptomatic patient, and the best therapeutic options are uncertain. Although several trials have been conducted on the treatment of CIT, clinical judgment is still used to determine the best treatment for right heart thrombus (RHT), especially when associated with pulmonary embolism (PE). In this review article, we discuss various diagnostic modalities and treatment options for this rare malady. We studied in detail their clinical impact on patients according to past research studies.

Clot In Transit in a Patient with Protein S Deficiency.

Clot in transit (CIT) is a rare condition in which a venous thromboembolism becomes lodged in the right heart. It is seen in up to 18% of patients with massive pulmonary embolism, and if left untreated, mortality rates are between 80% and 100%. The identification and management of CIT are crucial. However, there are no current guidelines for the treatment of CIT. We present the case of a 44-year-old woman who was found to have CIT that was ultimately treated with medical management.LEARNING POINTSClot in transit (CIT) is a dangerous entity that must be promptly managed.Risk factors for CIT include a history of heart failure, a pre-existing central venous catheter and recent hospitalization.New interventions are emerging for the treatment of CIT.

Right heart thrombi (RHT) and clot in transit with concomitant PE management: Approach and considerations.

Right heart thrombi (RHT) continues to pose a clinical dilemma for multiple specialties and is especially concerning when present with concomitant pulmonary embolism (PE). Patients with PE and RHT are at an increased risk of poor outcomes compared to PE without RHT. Although the exact incidence of RHT is unknown, the increasing use of point‐of‐care ultrasound may lead to an increased detection and frequency of RHT. There are multiple treatment strategies available for RHT, including anticoagulation, systemic thrombolysis, and endovascular and surgical therapies. Given that these treatment strategies involve multiple medical specialties, the management of RHT with concomitant PE can be complex. Currently, there is limited clinical data and guidelines on the treatment and management of RHT. We aim to provide a review on RHT with concomitant PE, including risk stratification, treatment considerations, and our approach to the management of RHT.

MULTIDISCIPLINARY APPROACH USING CATHETER DIRECTED MECHANICAL THROMBECTOMY IN TREATMENT OF A PULMONARY EMBOLISM WITH CLOT IN TRANSIT

TOPIC: Pulmonary Vascular Disease TYPE: Fellow Case Reports INTRODUCTION: Clot in transit (CIT) is a term associated with pulmonary embolism (PE) used to describe thrombus found in the right atrium or ventricle on echocardiography. We present a case of CIT treated in a multidisciplinary approach with catheter-directed mechanical thrombectomy. CASE PRESENTATION: A 60 year old male with a history of unprovoked PE off anticoagulation presented with dyspnea and syncope. At presentation, he was tachycardic to 130 but normotensive and not hypoxemic. Troponin-I was elevated at 0.06 ng/mL and B type-NP at 96 pg/mL. SARS-CoV-2 PCR was negative. CT angiography revealed extensive acute bilateral PE with increased RV/LV ratio of 1.9. A stat transthoracic echocardiography (TTE) found a dilated right ventricle with severely reduced systolic function, positive McConnell sign, a tricuspid annular plane systolic excursion (TAPSE) < 1cm, and a serpiginous mobile echodensity in the right atrium consistent with a CIT. A stat ultrasound of the legs also revealed extensive deep venous thrombosis in the proximal left femoral vein extending to the popliteal vein. After a multidisciplinary PE response team discussion, the patient was taken emergently to the catheterization lab. Prior to transport, VA ECMO safety lines were preemptively placed to facilitate ECMO initiation in case of decompensation. With the ECMO circuit primed and the ECMO team, cardiac anesthesiologist, and cardiothoracic surgery on standby, the patient underwent percutaneous mechanical thrombectomy utilizing the Inari Flowtriever® system. With adjunctive TTE guidance, the right atrial clot was first extracted in its entirety with no hemodynamic deterioration. This was followed by aspiration of clot from the right and left pulmonary arteries. Pulmonary artery pressures and cardiac index improved, and the procedure ended with placement of an IVC filter. The patient was transferred to the ICU and was started on enoxaparin at 1mg/kg twice a day. He was discharged on day 4 with rivaroxaban. DISCUSSION: CIT is a rare phenomenon with a prevalence rate of around 4% and is considered a medical emergency given its high mortality rate of 25-40%. While treatment guidelines are limited, anticoagulation alone has shown to be insufficient to treat CIT effectively. While there is data supporting the use of catheter directed therapies for PE, data on its use for CIT is scarce but growing. Furthermore, the preparation of advanced support prior in conjunction with the use of catheter directed therapy may be beneficial in case of life-threatening decompensation. CONCLUSIONS: Catheter-directed mechanical thrombectomy may be effective and safe as shown in this case, but requires a team capable of advanced therapies like ECMO and urgent surgical intervention if needed. REFERENCE #1: Otoupalova E, Dalal B, Renard B. Right heart thrombus in transit: a series of two cases. Crit Ultrasound J. 2017;9(1):14. doi:10.1186/s13089-017-0069-9. REFERENCE #2: Garvey S, Dudzinski DM, Giordano N, Torrey J, Zheng H, Kabrhel C. Pulmonary embolism with clot in transit: An analysis of risk factors and outcomes. Thromb Res. 2020 Mar;187:139-147. doi: 10.1016/j.thromres.2020.01.006. Epub 2020 Jan 10. PMID: 31991381. REFERENCE #3: Dhulipala V R, Fayoda B O, Kyaw H, et al. (August 04, 2020) Thrombus in Transit: Extract or Dissolve?. Cureus 12(8): e9550. doi:10.7759/cureus.9550. DISCLOSURES: No relevant relationships by Mara Caroline, source=Web Response No relevant relationships by Eliot Friedman, source=Web Response No relevant relationships by Eric Gnall, source=Web Responseresearch relationship with Inari Please note: April,2021 to presen Added 04/29/2021 by Lee Greenspon, source=Web Response, value=Grant/Research Support No relevant relationships by Patrick Ho, source=Web Response

Clot in Transit: Point-of-Care Ultrasound Diagnosis of Acute Pulmonary Embolism.

A 64-year-old man, who underwent a stent placement in his left external iliac vein 5 days prior, presented to the Emergency Department complaining of acute-onset shortness of breath. He denied any chest pain or leg swelling. Initial vital signs revealed a blood pressure of 115/70 mm Hg, heart rate of 130 beats/min, respiratory rate of 18 breaths/min, and O2 saturation of 92%, improving to 99–100% with nasal cannula and non-rebreather oxygen at flush rate (>40 L/min). Electrocardiogram revealed sinus tachycardia at 132 beats/min, poor R-wave progression, and ST depressions in V4–V6.

Emergent pulmonary embolectomy associated with clot in transit using FlowTriever aspiration device

Clot in transit (CIT) possesses a high mortality rate if left untreated hence timely management is required. Various treatment options, including endovascular procedures, are available. Currently, no consensus exists on superior treatment modality. Nevertheless, a multidisciplinary approach with a case-based evaluation seems the most appropriate. In the event of thrombolysis contraindication and hemodynamic instability, percutaneous mechanical thrombectomy should be considered. The success of the procedure is dependent on proper patient selection, as well as appropriate procedure guidance. The FlowTriever (Inari Medical Inc., Irvine, CA, USA) has proven efficacious for CIT treatment in several case reports. Based on the literature review, five out of six patients with CIT treated with the FlowTriever were discharged alive. Furthermore, the FLARE study reported an acceptable effectiveness profile in patients with Pulmonary Embolism (PE). This article presents currently available percutaneous mechanical thrombectomy alternatives focusing on the potential of the FlowTriever aspiration device.