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.