When Harry Met Sally: Single-Session INARI FlowTriever and Impella RP

Abstract

Percutaneous mechanical thrombectomy devices have revolutionized the treatment of massive pulmonary embolism (PE) by providing a rapid, non-thrombolytic based method to re-establish right-sided circulation while reducing bleeding complications. However, with massive PE, the acute increase in right ventricular afterload results in a compounded hemodynamic compromise, which may necessitate the need for advanced cardiac support. This case exemplifies the need for a comprehensive and synergistic approach to the management of massive PE. To our knowledge, this is the first report of combination therapy using large bore mechanical suction thrombectomy (FlowTriever, INARI Medical, Irvine, CA, USA) in conjunction with the implantation of right ventricular mechanical support (Impella RP, ABIOMED, Danvers, MA, USA) in an effort to reverse the right ventricular "shock spiral." <Learning objective: To understand the importance of timely intervention in massive pulmonary embolism (PE) and the role of percutaneous mechanical thrombectomy devices in such situations where thrombolysis fails or is contraindicated. To incorporate the simultaneous use of mechanical circulatory support in the setting of massive PE.>.

Keywords: Massive pulmonary embolism; Percutaneous mechanical thrombectomy; Right ventricular assist device; Right-sided cardiogenic shock.

Fig. 1

(A) Pre-procedure computed tomographic angiography of chest with the saddle embolus. (B) Post-procedure inverted digital subtraction pulmonary angiography showing resolution of the embolus.

Fig. 2

(A) FlowTriever placed in right pulmonary artery. (B) FlowTriever placed in left pulmonary artery, Swan-Ganz catheter in the right pulmonary artery. (C) Final position of Impella RP in the left pulmonary artery.

Fig. 3

Gross specimen of the extracted embolus.