We have reported on a novel use of the AngioVac suction thrombectomy device (AngioDynamics, Latham, NY) for vacuum-assisted embolic protection in a case of extensive mechanical thrombectomy of a caval–visceral deep vein thrombosis (DVT) that was refractory to standard catheter-directed thrombolysis. To the best of our knowledge, this is the first report of the use of a vacuum-assisted suction thrombectomy device for successful embolic protection. A 15-year-old girl had developed extensive, symptomatic bilateral ileocaval and renal vein DVTs refractory to outpatient management with anticoagulation therapy after pharmacomechanical thrombectomy and catheter-directed lysis. Initially, she had been treated successfully with overnight lytic therapy for the ileocaval DVT, and she was discharged with anticoagulation therapy. However, she had presented again with worsening bilateral lower extremity symptoms and kidney injury due to progression of the DVT. To prevent end-organ failure, extensive endovascular mechanical thrombectomy was planned. With the patient's significant thrombus burden through the visceral and retrohepatic inferior vena cava (IVC), pulmonary embolic protection during mechanical thrombectomy was our chief concern. Given the extent of the clot, IVC filter placement was impossible. Therefore, an AngioVac suction thrombectomy cannula and circuit was established via bilateral internal jugular vein access in an attempt to debulk the thrombus from a superior approach and provide pulmonary embolic protection. Mechanical thrombectomy (ClotTriever; Inari Medical, Irvine, Calif) was used to successfully debulk the IVC and bilateral ileofemoral venous segments from the bilateral popliteal veins. Although the use of the AngioVac from above proved unable to debulk the thrombus, it was successful in preventing significant embolism during ClotTriever mechanical thrombectomy (Fig 1). After mechanical thrombectomy (Fig 2), the patient's creatinine had returned to normal. She continued anticoagulation therapy, with Doppler ultrasound imaging showing reduction of the DVT and improvement of her lower extremity symptoms. We believe the present case has illustrated successful pulmonary embolic protection using a large-bore suction thrombectomy device with venoveno bypass during endovascular mechanical thrombectomy of caval, visceral, and bilateral ileofemoral DVTs. The AngioVac cannula and circuit can be safely and effectively used for central embolic protection in the case of large-volume caval mechanical thrombectomy.Fig 2Doppler ultrasound image showing reduction of the deep vein thrombosis (DVT) after mechanical thrombectomy.View Large Image Figure ViewerDownload Hi-res image Download (PPT)