Related Experiment Video
Updated: Nov 16, 2025
Catheter Ablation in Combination With Left Atrial Appendage Closure for Atrial Fibrillation
Published on: February 26, 2013
Left atrial appendage closure device implantation via transhepatic vascular access: a case report
Pegah Zare1, Luis Rechani2, Shaun Smithson2
1Internal Medicine, Aventura Hospital and Medical Center, 20900 Biscayne Blvd, Aventura, FL 33180, USA.
Insights
Transhepatic venous access offers a safe alternative for Watchman device implantation when femoral access is challenging. This approach is vital for patients with non-valvular atrial fibrillation needing left atrial appendage closure.
Area of Science:
- Cardiology
- Interventional Cardiology
- Medical Devices
Background:
- Non-valvular atrial fibrillation (NVAF) frequently leads to thrombi in the left atrial appendage (LAA), increasing stroke risk.
- The Watchman device provides an alternative to oral anticoagulation for LAA closure in NVAF patients intolerant to long-term anticoagulation.
- Standard transseptal access via the femoral vein may be challenging in some patients.
Purpose of the Study:
- To evaluate the feasibility and safety of transhepatic venous access for Watchman device implantation.
- To present a case of successful LAA closure using a transhepatic approach in a patient with occluded femoral veins.
Main Methods:
- A case study of an 81-year-old male with NVAF, heart failure with reduced ejection fraction, and diabetes mellitus.
- Initial attempt at transseptal access via the femoral vein was unsuccessful due to bilateral femoral and iliac vein occlusion.
- A transhepatic venous access route was utilized for successful Watchman device implantation.
Main Results:
- The transhepatic approach facilitated successful implantation of the Watchman device.
- The procedure was completed without complications.
- The patient was discharged on dual antiplatelet therapy (rivaroxaban and aspirin).
Conclusions:
- Transhepatic venous access is a viable and safe alternative for Watchman device implantation in patients with inadequate femoral venous access.
- This procedural option can significantly improve treatment options for select NVAF patients.
- Enhanced understanding of alternative access routes improves patient care and device delivery success.
Background:
In patients with non-valvular atrial fibrillation, an estimated 90% of thrombi are located in the left atrial appendage. The WATCHMAN device is a left atrial appendage closure device that is an alternative therapeutic option to reduce the risk of systemic embolization in patients who are intolerant of long-term oral anticoagulation. It can be deployed in the left atrial appendage using a transseptal approach via the femoral vein. Transhepatic venous access is an alternative route for the delivery of the device in a patient with difficult vascular access.
Case Summary:
An 81-year-old man with persistent non-valvular atrial fibrillation, heart failure with reduced ejection fraction (HFrEF), and diabetes mellitus was deemed a poor candidate for anticoagulation due to recurrent falls and gastrointestinal bleeding. He was selected for a left atrial appendage closure. The initial procedure was aborted after significant resistance to device advancement was encountered in the right femoral vein. Lower extremity venography demonstrated totally occluded femoral and iliac veins bilaterally. The decision was made to implant the device via a transhepatic approach. The procedure had no complications and the patient was discharged on rivaroxaban and aspirin after 3 days.
Discussion:
Transhepatic venous access is a viable option in patients with poor femoral access for implantation of the WATCHMAN device. It can be done safely. Knowledge of this procedural alternative can greatly enhance patient care.
