Novel percutaneous aspiration thrombectomy in Fontan conduit obstruction with cardiogenic shock. Case report

Abstract

Background: Obstructive complications in the Fontan circulation pose significant risks to affected patients. Traditional management strategies may be insufficient, necessitating innovative treatment approaches. This case report discusses the use of the FlowTriever Retrieval System for percutaneous aspiration thrombectomy in a patient with a history of Fontan procedure who developed conduit obstruction due to thrombus formation.

Case report: A 28-year-old male with a history of double inlet left ventricle and previous Fontan procedure presented with progressive dyspnea. Despite initial thrombectomy for high-risk pulmonary embolism, thrombi remained in the Fontan conduit and inferior vena cava. The patient remained hemodynamically unstable. Imaging confirmed thrombosis of the extracardiac conduit. An innovative percutaneous approach using the FlowTriever system successfully restored conduit flow and removed thrombus. Subsequent stenting addressed residual stenosis. Post-intervention, the patient showed remarkable clinical improvement. There were no procedure-related complications. He was discharged on an optimized anticoagulation regimen and remained asymptomatic during follow-up.

Conclusion: This case demonstrates the efficacy of the FlowTriever Retrieval System in managing complex thrombotic obstructions in Fontan circulation, which not only effectively resolved the obstruction but also maintained haemodynamic stability, thus highlighting its potential to enhance current treatment modalities for such congenital heart conditions.

Fig. 1

Summary of the Procedure Sequence and Final Result. A: Advancement of a coronary wire through the Gore-Tex conduit to the pulmonary arteries with the support of a 5F multipurpose catheter. Angulation of the Gore-Tex conduit was observed. B: Angiography performed in the superior vena cava showing patent pulmonary arteries and occlusion of the Gore-Tex conduit. C: Advancement of a 20F FlowTriever catheter to the IVC. D: An angiography performed in the IVC confirmed the occlusion of the extracardiac conduit. E: After multiple aspirations, flow towards the pulmonary arteries was restored, with minimal residual thrombus. F: Due to an angulated stenosis of the conduit, a covered stent mounted over an 18mm Balloon-in-Balloon catheter was implanted. G: Central infraexpansion due to severe calcification was observed, and a second 45 mm CP stent was implanted. H: Final angiography showing restored normal flow towards the pulmonary arteries, with no residual stenosis. IVC: Inferior Vena Cava.