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AngioVac Removal of a Saddle Pulmonary Embolus Using TEE Guidance and Venoarterial ECMO Support.

VENOUS THROMBOEMBOLIC disease is a significant cause of morbidity and mortality, and in patients with hemodynamic instability, intervention with thrombolysis or embolectomy is indicated. In patients whose condition is otherwise stable, the use of thrombolysis or embolectomy has been advocated in the presence of right ventricular strain, patent foramen ovale, extensive clot burden, free-floating right heart thrombus, or severe hypoxemia. When the risk of bleeding precludes the use of thrombolytics, either surgical or catheter-based embolectomy prevails as the most acceptable treatment option. The Vortex AngioVac system (Vortex Medical, Inc; Marlborough, MA) is a catheter-based embolectomy system approved by the U.S. Food and Drug Administration for the percutaneous retrieval of unwanted intravascular material. The AngioVac cannula is paired with a thrombus filter, a centrifugal pump head, and a reinfusion cannula that returns blood to the patient’s venous circulation. The authors present a case in which the AngioVac system was used to retrieve a saddle pulmonary embolus under transesophageal echocardiographic (TEE) guidance. Because of concern for cardiorespiratory collapse during the procedure, the reinfusion cannula was modified with the addition of a venoarterial extracorporeal membrane oxygenation (ECMO) circuit.