Techniques to Mitigate Risk of Intraprocedural Complications During Large Bore Aspiration Thrombectomy for Pulmonary Embolism

Monday, March 31, 2025

5:15 PM – 5:20 PM CT

Location: Music City Center, 202 BC

Abstract Presenter(s)

Michael Novack, MD

Integrated IR/DR Resident
Stanford Health Care, United States

Author/Co-author(s)

MH

Mohammed Hayat, M.S., MD

Interventional Radiology Resident, PGY-3
Stanford University, United States
AK

Andrew Kesselman, MD

Clinical Associate Professor
Stanford Medicine, United States
Lynne Martin, MD

Resident
Stanford, United States
LH

Lawrence (Rusty) V. Hofmann, MD, FSIR

Professor
Stanford University Medical Center, United States
PA

Pascal Acree, MD

IR/DR Resident
Stanford Health Care, United States

Learning Objectives:

Understand the principles and techniques of large bore aspiration thrombectomy (LBAT) for pulmonary embolism (PE).

Familiarize oneself with potential intraprocedural complications associated with LBAT.

Explore techniques for risk mitigation to improve patient outcomes.

Background: PE is a significant cause of mortality and morbidity with LBAT emerging as a promising therapeutic option. However, LBAT is not without its risks including intraprocedural complications. Implementation of strategies to mitigate risks can optimize patient safety and outcomes.

Clinical Findings/Procedure Details:

Patient Selection: Assess patient risk factors (coagulopathy, contraindication to anticoagulation, cardiac abnormalities).

Imaging: Ideally, have a large, centrally located clot burden.

Anesthesia: Choose appropriate anesthesia minimizing hemodynamic instability. Avoid propofol. Communicate with anesthesiologist during the procedure. Consider intraprocedural TEE.

Multidisciplinary

Discussion: Discuss patient management with primary team, ICU/pulmonology, and cardiothoracic team. Consider ECMO candidacy.

Pharmacological Adjuncts: Administer intraprocedural heparin/AC to prevent thrombus formation.

Access: Choose internal jugular or femoral vein access based on patency/size, patient anatomy/imaging, equipment availability, and hemostasis safety.

Procedure and Catheterization: Use appropriate size and length catheters/sheaths. Use balloon-tipped or pigtail-shaped catheters for pulmonary artery selection to avoid chordae tendineae rupture and severe TR. Avoid high-pressure/volume angiograms.

Thrombectomy: Accurately engage clot and limit aspirational volumes to decrease blood loss. Consider using devices that limit aspiration or return non-thrombosed blood. If the patient becomes acutely unstable, consider salvage TPA. Discuss cell saver risks/benefits.

Conclusion and/or Teaching Points: Intraprocedural complications during LBAT for PE can significantly impact patient outcomes. Through the implementation of a comprehensive approach that addresses risk factors, employs proper techniques, and considers appropriate patient selection, clinicians can improve the safety and efficacy of LBAT.