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Case Reports
. 2025 Aug 27;30(25):104943.
doi: 10.1016/j.jaccas.2025.104943.

Transjugular Access for Left Atrial Appendage Closure

Ahmed Hussein  1 , Ariana Ehsan  2 , Adriana Olivares  2 , Thomas Waggoner  3
Affiliations
Case Reports

Transjugular Access for Left Atrial Appendage Closure

Ahmed Hussein et al. JACC Case Rep. .

Abstract

Background: Percutaneous left atrial appendage closure (LAAC) is an established therapy for stroke prevention in atrial fibrillation patients unable to tolerate long-term oral anticoagulation. Transfemoral access is standard, but may be precluded by chronic venous occlusion, severe iliocaval tortuosity, or other anatomical barriers.

Case summary: We describe 2 patients with paroxysmal atrial fibrillation, elevated thromboembolic risk, and absolute contraindications to anticoagulation who were unsuitable for transfemoral LAAC due to prohibitive femoral venous anatomy. In both cases, right internal jugular venous access was obtained, and trans-septal puncture was performed using a steerable sheath and adjunctive wire strategies to optimize trajectory. A Watchman FLX Pro device was successfully implanted in each patient without periprocedural complications, and follow-up imaging confirmed stable position and complete appendage seal.

Discussion: The transjugular approach is a technically feasible alternative in cases where transfemoral access cannot be achieved.

Take-home message: In anatomically challenging cases, transjugular LAAC can achieve successful outcomes with appropriate technique and equipment.

Keywords: TruSteer sheath; Watchman device; alternative venous access; atrial fibrillation; left atrial appendage closure; structural heart intervention; transjugular access.

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Conflict of interest statement

Funding Support and Author Disclosures Dr Waggoner, is a consultant for Boston Scientific, the manufacturer of the Watchman device and the TrueSteer sheath used in this case series. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Figures

None
Graphical abstract
Figure 1
Figure 1
Transjugular LAAC Procedure (Case 1) (A) Preprocedural cardiac CT showing the anteriorly directed LAA. (B) Septal tenting with the steerable VIZIGO sheath. (C) Guidewire advanced into the pulmonary vein. (D) Safari wire positioned in the left ventricle to facilitate sheath advancement. CT = computed tomography; LAA = left atrial appendage; LAAC = left atrial appendage closure.
Figure 2
Figure 2
Transjugular LAAC Procedure (Case 2) (A) CT image demonstrating anterior “chicken wing” LAA morphology. (B) Fluoroscopy showing 5 pacemaker/ICD leads in the SVC. (C) Tenting of the interatrial septum using the VIZIGO sheath for entry via the iatrogenic ASD. ASD = atrial septal defect; CT = computed tomography; ICD = implantable cardioverter-defibrillator; LAA = left atrial appendage; LAAC = left atrial appendage closure; SVC = superior vena cava
Figure 3
Figure 3
Technique for Mid-Deployment Steering Using the TruSteer Sheath Illustration of steerable sheath positioning for coaxial alignment during LAAC deployment. Image courtesy of Boston Scientific; used with permission. LAA = left atrial appendage; LAAC = left atrial appendage closure; RO = radiopaque.
See this image and copyright information in PMC

References

    1. Reddy V.Y., Doshi S.K., Kar S., et al. 5-Year outcomes after left atrial appendage closure: from the PREVAIL and PROTECT AF trials. J Am Coll Cardiol. 2017;70(24):2964–2975. doi: 10.1016/j.jacc.2017.10.021. - DOI - PubMed
    1. Morcos R., Al Tahii H., Bansal P., Manam R., Maini B. Transhepatic vascular access for implantation of a watchman left atrial appendage closure device. Reports. 2018;1(2):15.
    1. Girgis S., Rechani L., Smithson S. Complex transcatheter left atrial appendage closure using a tailored trans-jugular approach simulated by 3D printing: a case report. Eur Heart J Case Rep. 2022;6(10):ytac304. - PMC - PubMed
    1. Boston Scientific . Boston Scientific Corporation; 2024. TruSteer™ Steerable Sheath – Instructions for Use.

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