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Semin intervent Radiol 2022; 39(05): 515-522
DOI: 10.1055/s-0042-1757942
Review Article

Right Heart Clot-in-Transit: Endovascular Therapies

Sipan Mathevosian
1   Division of Interventional Radiology, Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, California
,
Mona Ranade
1   Division of Interventional Radiology, Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, California
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Abstract

Right heart thrombus is a challenging high mortality disease typically seen in the setting of pulmonary embolism. Traditional treatments have included anticoagulation, thrombolysis, and surgical embolectomy. Advances in recognition and treatment of clot-in-transit have led to the development of endovascular therapies increasingly becoming the preferred method of treatment due to rapid debulking and lower morbidity. Novel endovascular devices are large bore aspiration thrombectomy systems which mitigate the use of concomitant thrombolytics. The article reviews the disease process, relevant literature, and current endovascular devices and strategies for the treatment of right heart thrombus and clot-in-transit.

Keywords

right heart thrombus - pulmonary embolism - aspiration thrombectomy

Financial Disclosures

M.R. is a paid consultant for AngioDynamics Inc. and Inari Medical.




Publication History

Article published online:
20 December 2022

© 2022. Thieme. All rights reserved.

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  • References

  • 1 Barrios D, Rosa-Salazar V, Jiménez D. et al; RIETE Investigators. Right heart thrombi in pulmonary embolism. Eur Respir J 2016; 48 (05) 1377-1385
    CrossrefPubMedSearch in Google Scholar
  • 2 Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative Pulmonary Embolism Registry (ICOPER). Lancet 1999; 353 (9162): 1386-1389
    CrossrefPubMedSearch in Google Scholar
  • 3 Muramoto H, Niwa A, Satoh Y. et al. Clinical significance and prognosis of right heart thrombi associated with acute pulmonary thromboembolism - results of a multicenter registry of thrombolysis in Japan. Circ J 2021; 85 (04) 353-360
    CrossrefPubMedSearch in Google Scholar
  • 4 Barkhausen J, Hunold P, Eggebrecht H. et al. Detection and characterization of intracardiac thrombi on MR imaging. AJR Am J Roentgenol 2002; 179 (06) 1539-1544
    CrossrefPubMedSearch in Google Scholar
  • 5 Leibowitz G, Keller NM, Daniel WG. et al. Transesophageal versus transthoracic echocardiography in the evaluation of right atrial tumors. Am Heart J 1995; 130 (06) 1224-1227
    CrossrefPubMedSearch in Google Scholar
  • 6 European Working Group on Echocardiography. The European Cooperative Study on the clinical significance of right heart thrombi. Eur Heart J 1989; 10 (12) 1046-1059
    CrossrefPubMedSearch in Google Scholar
  • 7 Islam M, Nesheim D, Acquah S. et al. Right heart thrombi: patient outcomes by treatment modality and predictors of mortality: a pooled analysis. J Intensive Care Med 2019; 34 (11-12): 930-937
    CrossrefPubMedSearch in Google Scholar
  • 8 Koć M, Kostrubiec M, Elikowski W. et al; RiHTER Investigators. Outcome of patients with right heart thrombi: the Right Heart Thrombi European Registry. Eur Respir J 2016; 47 (03) 869-875
    CrossrefPubMedSearch in Google Scholar
  • 9 Lichtenberger III JP, Reynolds DA, Keung J, Keung E, Carter BW. Metastasis to the heart: a radiologic approach to diagnosis with pathologic correlation. AJR Am J Roentgenol 2016; 207 (04) 764-772
    CrossrefPubMedSearch in Google Scholar
  • 10 Moriarty JM, Al-Hakim R, Bansal A, Park JK. Removal of caval and right atrial thrombi and masses using the AngioVac Device: initial operative experience. J Vasc Interv Radiol 2016; 27 (10) 1584-1591
    CrossrefPubMedSearch in Google Scholar
  • 11 Fuchs S, Pollak A, Gilon D. Central venous catheter mechanical irritation of the right atrial free wall: A cause for thrombus formation. Cardiology 1999; 91 (03) 169-172
    CrossrefPubMedSearch in Google Scholar
  • 12 Gilon D, Schechter D, Rein AJ. et al. Right atrial thrombi are related to indwelling central venous catheter position: insights into time course and possible mechanism of formation. Am Heart J 1998; 135 (03) 457-462
    CrossrefPubMedSearch in Google Scholar
  • 13 Clark JR, Hoffman SC, Shlobin NA, Bavishi A, Narang A. Incidence of catheter-associated right atrial thrombus detected by transthoracic echocardiogram. Echocardiography 2021; 38 (03) 435-439
    CrossrefPubMedSearch in Google Scholar
  • 14 Stavroulopoulos A, Aresti V, Zounis C. Right atrial thrombi complicating haemodialysis catheters. A meta-analysis of reported cases and a proposal of a management algorithm. Nephrol Dial Transplant 2012; 27 (07) 2936-2944
    CrossrefPubMedSearch in Google Scholar
  • 15 Chick JFB, Reddy SN, Bhatt RD, Shin BJ, Kirkpatrick JN, Trerotola SO. Significance of echocardiographically detected central venous catheter tip-associated thrombi. J Vasc Interv Radiol 2016; 27 (12) 1872-1877
    CrossrefPubMedSearch in Google Scholar
  • 16 Chiang J, Mathevosian S, Aboulhosn J, Moriarty JM. Prevention of paradoxical cerebral embolus with protection system during combination right atrial clot aspiration thrombectomy and closure of patent foramen ovale. Arab J Interv Radiol 2021; 5 (01) 52-55
    Thieme ConnectPubMedSearch in Google Scholar
  • 17 Patel N, Azemi T, Zaeem F. et al. Vacuum assisted vegetation extraction for the management of large lead vegetations. J Card Surg 2013; 28 (03) 321-324
    CrossrefPubMedSearch in Google Scholar
  • 18 Baddour LM, Epstein AE, Erickson CC. et al; American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in Young, Council on Cardiovascular Surgery and Anesthesia, Council on Cardiovascular Nursing, Council on Clinical Cardiology, Interdisciplinary Council on Quality of Care, American Heart Association. Update on cardiovascular implantable electronic device infections and their management: a scientific statement from the American Heart Association. Circulation 2010; 121 (03) 458-477
    CrossrefPubMedSearch in Google Scholar
  • 19 Jaff MR, McMurtry MS, Archer SL. et al; American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, American Heart Association Council on Peripheral Vascular Disease, American Heart Association Council on Arteriosclerosis, Thrombosis and Vascular Biology. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific statement from the American Heart Association. Circulation 2011; 123 (16) 1788-1830
    CrossrefPubMedSearch in Google Scholar
  • 20 Athappan G, Sengodan P, Chacko P, Gandhi S. Comparative efficacy of different modalities for treatment of right heart thrombi in transit: a pooled analysis. Vasc Med 2015; 20 (02) 131-138
    CrossrefPubMedSearch in Google Scholar
  • 21 Rose PS, Punjabi NM, Pearse DB. Treatment of right heart thromboemboli. Chest 2002; 121 (03) 806-814
    CrossrefPubMedSearch in Google Scholar
  • 22 Torbicki A, Galié N, Covezzoli A, Rossi E, De Rosa M, Goldhaber SZ. ICOPER Study Group. Right heart thrombi in pulmonary embolism: results from the International Cooperative Pulmonary Embolism Registry. J Am Coll Cardiol 2003; 41 (12) 2245-2251
    CrossrefPubMedSearch in Google Scholar
  • 23 Kanter DS, Mikkola KM, Patel SR, Parker JA, Goldhaber SZ. Thrombolytic therapy for pulmonary embolism. Frequency of intracranial hemorrhage and associated risk factors. Chest 1997; 111 (05) 1241-1245
    PubMedSearch in Google Scholar
  • 24 Chatterjee S, Chakraborty A, Weinberg I. et al. Thrombolysis for pulmonary embolism and risk of all-cause mortality, major bleeding, and intracranial hemorrhage: a meta-analysis. JAMA 2014; 311 (23) 2414-2421
    CrossrefPubMedSearch in Google Scholar
  • 25 Meyer G, Vicaut E, Danays T. et al; PEITHO Investigators. Fibrinolysis for patients with intermediate-risk pulmonary embolism. N Engl J Med 2014; 370 (15) 1402-1411
    CrossrefPubMedSearch in Google Scholar
  • 26 Moriarty JM, Rueda V, Liao M. et al. Endovascular removal of thrombus and right heart masses using the AngioVac system: results of 234 patients from the Prospective, Multicenter Registry of AngioVac Procedures in Detail (RAPID). J Vasc Interv Radiol 2021; 32 (04) 549-557.e3
    CrossrefPubMedSearch in Google Scholar
  • 27 D'Ayala M, Worku B, Gulkarov I, Sista A, Horowitz J, Salemi A. Factors associated with successful thrombus extraction with the AngioVac device: an institutional experience. Ann Vasc Surg 2017; 38: 242-247
    CrossrefPubMedSearch in Google Scholar
  • 28 Basman C, Rashid U, Parmar YJ, Kliger C, Kronzon I. The role of percutaneous vacuum-assisted thrombectomy for intracardiac and intravascular pathology. J Card Surg 2018; 33 (10) 666-672
    CrossrefPubMedSearch in Google Scholar
  • 29 Callese TE, O'Brien DP, Wilhalme H, Yang EH, Moriarty JM. AngioVac aspiration thrombectomy of right atrial thrombus is safe and effective in cancer patients. Ann Vasc Surg 2021; 77: 243-254
    CrossrefPubMedSearch in Google Scholar
  • 30 Al-Hakim R, Park J, Bansal A, Genshaft S, Moriarty JM. Early experience with AngioVac aspiration in the pulmonary arteries. J Vasc Interv Radiol 2016; 27 (05) 730-734
    CrossrefPubMedSearch in Google Scholar
  • 31 Tu T, Toma C, Tapson VF. et al; FLARE Investigators. A prospective, single-arm, multicenter trial of catheter-directed mechanical thrombectomy for intermediate-risk acute pulmonary embolism: the FLARE study. JACC Cardiovasc Interv 2019; 12 (09) 859-869
    CrossrefPubMedSearch in Google Scholar
  • 32 Shin DS, Monroe EJ, Bertino FJ, Abad-Santos M, Abajian A, Chick JFB. Portomesenteric venous thrombectomy using Inari Triever aspiration catheter (FlowTriever). Cardiovasc Intervent Radiol 2022; 45 (01) 131-133
    CrossrefPubMedSearch in Google Scholar
  • 33 Nezami N, Latich I, Murali N. et al. Right atrial and massive pulmonary artery mechanical thrombectomy under echocardiography guidance using the FlowTriever system. EJVES Short Rep 2019; 45: 22-25
    CrossrefPubMedSearch in Google Scholar
  • 34 Bayona Molano MDP, Salsamendi J, Mani N. Emergent mechanical thrombectomy for right atrial clot and massive pulmonary embolism using FlowTriever. Clin Case Rep 2021; 9 (03) 1241-1246
    CrossrefPubMedSearch in Google Scholar
  • 35 Shah NG, Wible BC, Paulisin JA. et al. Management of inferior vena cava thrombosis with the FlowTriever and ClotTriever systems. J Vasc Surg Venous Lymphat Disord 2021; 9 (03) 615-620
    CrossrefPubMedSearch in Google Scholar
  • 36 Angiodynamics, Inc.. Evaluating the Safety and Efficacy of the AlphaVac Multipurpose Mechanical Aspiration (MMA) F1885 PE for Treatment of Acute Pulmonary Embolism. clinicaltrials.gov; 2022. Accessed April 24, 2022 at: https://clinicaltrials.gov/ct2/show/NCT05318092
    PubMed