Abstract 4364777: Management of a Clot in Transit in a Patient with a Patent Foramen Ovale

Background: The clinical presentation of patients with acute pulmonary embolism (PE) greatly varies and can range from incidental imaging findings in asymptomatic patients to sudden cardiac death. The management depends upon patient risk and hemodynamic profiles, which is further complicated in patients with a clot in transit (CIT) due to the risk of clinical deterioration and an increased mortality (~25-40 %). Here we present a case of an intermediate high-risk PE with a CIT and a patent foramen ovale with extension of clot from the right to left atrium. Case Description: A 69-year old nursing home resident, bedbound from a previous motor vehicle accident and multiple lumbar fusions presents with sudden onset shortness of breath. On initial evaluation, the patient was hypoxic requiring high flow nasal cannula and point of care ultrasound echocardiography showed a CIT ( Figure 1 ). CT PE showed extensive bilateral PE’s with a CIT in the RA ( Figure 2 ). PERT decision was made to take the patient for urgent thrombectomy with ECMO backup. Peri-procedure TTE guidance was utilized to assist with retrieval of the CIT, and a sizable thrombus straddling a patent foramen ovale going from the right to left atrium was noted. Given the patient’s prohibitive surgical risk as determined by CTS, the decision was made to proceed with thrombectomy and percutaneous removal of the CIT with 3D echocardiographic guidance ( Figure 3 ). At the conclusion of the case, all thrombus was successfully removed with the INARI FlowTriever 24 Fr catheter from bilateral pulmonary arteries in addition to the CIT extending from the right to left atrium that was retrieved utilizing the INARI FlowTriever 20 Fr Curved catheter ( Figure 2 ). The patient was monitored in the CCU and then discharged several days later to a skilled nursing facility in stable condition. Discussion: Decisions regarding the management of patients with pulmonary embolism and CIT is complex. This is especially true for this case where there was extension of clot from the right to left atrium increasing the risk of stroke. Here we report the case of a patient who presented with symptomatic intermediate high-risk PE and a CIT with a patent foramen ovale, where a successful thrombectomy was performed. In this high-risk case, mechanical thrombectomy served as a lifesaving management strategy that likely prevented clinical decompensation in this patient.