Operative Technique
The procedure was performed using C-arm fluoroscopy and transesophageal
echocardiography (TEE) by a cardiac surgeon experienced in
catheter-based and surgical embolectomy. Intraoperative TEE demonstrated
a markedly dilated RV and underfilled left ventricle (LV) with
hyperdynamic LV function. Upon general anesthesia induction and
intubation, guidewires were placed in both common femoral veins (CFV)
and advanced into the IVC under fluoroscopic guidance. The patient was
anticoagulated with heparin, and next, a 26F dry-seal sheath (Gore
Medical) was placed in the right CFV for the AngioVac cannula and an 18F
cannula was placed in the left CFV for the reinfusion cannula. The
AngioVac catheter was introduced through the right groin sheath and
advanced into the IVC prior to connecting it to the venous inflow tubing
of the VV bypass circuit after proper deairing maneuvers. The system was
then connected to the roller pump. The AngioVac catheter was carefully
advanced under fluoroscopic and echocardiographic guidance, as the pump
was started at 1 L/min and gradually increased to flow rate of 2.5 L/min
under fluoroscopic and echocardiography guidance. The catheter was then
advanced to the IVC-RA junction, at which point a large thrombus was
suctioned into the filter (Figure 2 ). A second thrombus was
evacuated upon further advancement into the RA. We verified that no
remaining clot was visible in the RA and RV using TEE and proceeded to
come off VV bypass by shutting down the pump gradually. Both cannulas
were removed, and groin sites repaired. The entire procedure was without
complications.