Percutaneous Extraction of a Large Device Related Thrombus on a Watchman™ Device: A Case Report

Background Left atrial appendage occlusion devices are commonly used to prevent stroke in patients with persistent atrial fibrillation who are unable to tolerate anticoagulation. However certain patient and device related characteristics increase the risk for the development of a device related thrombus. The presence of a device related thrombus increases the risk of stroke and should be treated. Management of device related thrombus lacks consensus but is mostly focused on anticoagulation. In patients with large thrombi that need to be managed urgently, percutaneous extraction may be a viable option. Case Summary In this report we describe the successful management of a device related thrombus via percutaneous thrombus extraction technology in an 81-year-old woman with a large thrombus attached to a WATCHMAN™ device. The patient initially presented with shortness of breath, and on imaging a pedunculated thrombus was detected. The thrombus was extracted using a Penumbra Lightning 12™ (Penumbra Inc., Alameda, CA) catheter with a Sentinel™ (Boston Scientific, Marlborough, Massachusetts) cerebral embolic protection device. The patient had no neurologic sequelae and was started on anticoagulation. Discussion Percutaneous thrombectomy can be safely performed to extract large left atrial occlusion device related thrombus that require urgent management, without any neurologic sequelae. We believe this can be used in patients with a large device related thrombus who would not be adequately managed with anticoagulation and in whom surgery is not feasible.

Percutaneous Extraction of Big Kidney Stone without Fragmentation: The Novel Technique in Percutaneous Nephrolithotomy (EN BLOCK PCNL)

PCNL is gold standard treatment of pelvis stone more than 2 cm. Since 1970 that PCNL was introduced, multiple methods including mini PCNL, Lap assisted PCNL and etc. were used to increase the efficacy and decrease the complications of PCNL in different patients. We describe a new method of PCNL for the first time for extracting 7 cm renal stone without fragmentation and we called it EN BLOCK PCNL. Our technique had no complication and caused lower operative time and hospital stay.

Clinical outcomes of early infective endocarditis vegetation extraction with AngioVac sytem

Funding Acknowledgements Type of funding sources: None. Purpose To describe our institutional experience in right-sided vegetation extraction using a percutaneous system and report our outcomes including mortality, ICU length of stay (LOS), hospital length of stay, decline in inflammatory markers, leukocytosis and bacteremia. Background Right-sided infective endocarditis (IE) has become increasingly common due to the growing incidence of intravenous drugs use (IVDU). Patients with large vegetations are often considered candidates for surgical extraction. However, high rates of recurrence in IVDU population and high surgical mortality are prohibitive of surgeries. Percutaneous extraction of right-sided masses has become an alternative to open heart surgery and can be performed with lower morbidity and mortality in patients with right sided IE. Percutaneous vegetation extraction facilitates functional recovery in critical care setting and influence outcomes in patients with elevated perioperative risk or concerns for recurrent IE. Methods A total of 3 patients with right sided IE underwent percutaneous vegetation extraction with AngioVac® system (AngioDynamics Inc., Latham, NY) under combined fluoroscopy and transesophageal echocardiography (TEE) guidance. Results In hospital mortality was 0%, average ICU LOS was 8 days and average hospital LOS was 4 weeks. There was a decrease in inflammatory marker and white blood cell (WBC) count after AngioVac procedure. Conclusion We report our experience with high risk IE patients. These patients had large vegetations, persistent bacteremia, right heart failure with prohibitive risk profiles during the perioperative period. AngioVac was effective in reducing bacteremia burden and reducing ICU stay. There were no procedure related complications. Overall percutaneous extraction of right-sided masses and vegetations have the potential of improving outcomes, reducing complications and healthcare costs in patients with right-sided IE. Table 1AgeSexVegetation LocationDevice usedMicroorganismPatient intubated for the procedure (y/n)ICU LOSHospital LOSDischarge death or aliveDecrease in WBCDecrease in ESRPatient #122MTVAngioVacMSSAY2 days3 weeksAlive768Patient #2`38MTVAngioVacMSSAY1 day2 weeksAlive229Patient #334FTV, RVOTAngioVacMRSAY20 days8 weeksAlive8Clinical characteristics and outcomes of patients with IE undergoing percutaneous extractions of right-sided vegetationsAbstract Figure. Picture 1