SIR 2024
Venous Interventions
Laura E. Stevens, MD
Resident Physician
UT Southwestern Medical Center
Financial relationships: Full list of relationships is listed on the CME information page.
Rehan Quadri, MD
Assistant Professor
UT Southwestern Medical Center
Disclosure information not submitted.
Sreeja Sanampudi, MD
Resident Physician
UT Southwestern Medical Center
Disclosure information not submitted.
Triet Do, MD
Resident Physician - Interventional Radiology
University of Texas Southwestern Medical Center
Disclosure information not submitted.
Sang Bum Lee
Disclosure information not submitted.
CIT is defined as free thrombus in the right heart chambers. The most common type results from migrated deep venous thrombus. The prevalence of CIT is not established, however most commonly occurs in patients with structural heart defects {1}. CIT carries substantial morbidity and mortality if left untreated, owing to risk of migration into the main pulmonary artery and subsequent cardiopulmonary collapse {2}.
Treatment strategies include systemic anticoagulation, systemic thrombolysis, endovascular/catheter directed, and surgical embolectomy; however, no treatment standard has been established {3}. Early endovascular devices employed a veno-venous bypass circuit and commonly resulted in significant blood loss. Early device operators had difficulty extracting clot due to limited fluoroscopic visualization and small suction catheter size.
Clinical Findings/Procedure Details:
Over a two-year period, we evaluated and treated 13 CIT patients. Modalities utilized for CIT diagnosis in our patients included computed tomography angiography (CTA), trans-thoracic echocardiography (TTE), and ICE. 2/9 patients showed signs of RV dysfunction. 6/9 patients showed evidence of adherent thrombus, while 3/9 had free-floating thrombus: each posing unique intra-operative considerations during removal.
We utilized a 24 French IFT system with ICE. When used in combination, the operator is allowed dynamic targeting of the thrombus limiting blood loss with the use of the FlowSaver Blood Return System. Pictorial essay from our patient cases will be used to detail this procedure.
In addition, we will discuss pre-procedure planning, post-operative considerations and lessons learned through examples of interatrial shunt and propagated clot from a TIPS and central venous structures.
Conclusion and/or Teaching Points: As techniques to treat clot-in-transit evolve, interventional radiologists are becoming center-point in the care of these critically ill patients, necessitating detailed understanding of treatment options. In this educational exhibit, we present a comprehensive imaging and technical review for management of CIT using IFT and ICE as detailed through a case series from two of our large academic hospitals.