Percutaneous Aspiration of Ascending Aortic Mural Thrombus Under Intra-Aortic Intracardiac Echocardiographic Guidance

Ascending aortic mural thrombus can be highly mobile and cause systemic embolization, even without aneurysm or advanced atherosclerosis.

A 57-year-old man with coronary artery disease, prior coronary artery bypass grafting, chronic obstructive pulmonary disease, and recent orthopedic surgery presented with chest tightness and cough. Computed tomography angiography revealed a multilobulated ascending aortic mural thrombus measuring 26 × 11 mm. Despite heparin therapy, he developed acute right internal carotid artery occlusion requiring thrombectomy. Follow-up imaging showed persistent mobile thrombi, and transesophageal echocardiography (TEE) was limited. Percutaneous debulking using the AngioVac system with intracardiac echocardiography (ICE) guidance successfully removed the thrombus without complications.

This case demonstrates a novel percutaneous approach for ascending aortic thrombus removal using intra-aortic ICE to overcome TEE blind spots, allowing safe, targeted aspirations.

TEE has blind spots in the proximal ascending aorta. ICE provides real-time guidance, facilitating safer real-time procedural visualization and AngioVac thrombus aspirations.