Implantation of Left Ventricular Assist Device After Descending Aortic Stent Graft for Mural Thrombus

In patients with intraluminal thrombus, commonly applied temporary circulatory support modalities are contraindicated secondary to concern regarding distal or proximal (specifically veno-arterial extracorporeal membrane oxygenation) embolization of the thrombus. Therefore, in patients with cardiogenic shock and synchronous intraluminal descending aortic thrombus, support options are quite limited. We report a case of a 66-year-old man in cardiogenic shock, due to an ischemic cardiomyopathy, who also had intramural thrombus with an intraluminal component in the descending thoracic aorta. An endovascular stent graft was inserted inside the aorta over the location of the mural thrombus. This allowed for the placement of an intra-aortic balloon pump (IABP) for pre-operative optimization. After 3 days, a left ventricular assist device (LVAD) was implanted via left anterolateral thoracotomy with hemi-sternotomy, and the IABP was removed. Post-operatively, he had a relatively uncomplicated course without signs of embolic phenomena and ultimately was discharged home. Surveillance computed tomography imaging at 6 months showed no endovascular leak or migration of the stent. This case demonstrates the feasibility of aortic stent graft placement to allow safe insertion of an IABP in the setting of aortic mural thrombus.  Furthermore, it demonstrates the safety and feasibility of LVAD implantation after recent aortic stent graft placement.