Transjugular Watchman Implantation for Left Atrial Appendage Occlusion in Anomalous Inferior Vena Cava

We report a successful right transjugular Watchman device implantation for left atrial appendage (LAA) occlusion in a patient with anomalous inferior vena cava with azygos continuation, precluding standard transfemoral venous access.

Ultrasound-guided right internal jugular venous access was obtained and upsized to accommodate the delivery system. Transseptal puncture was performed using an Agilis NxT medium-curve steerable sheath with microcatheter and wire exchanges, followed by staged balloon septal dilatation. The delivery sheath was successfully advanced into the LAA, and the Watchman device was successfully deployed.

Transjugular LAA occlusion presents unique challenges, including an angulated trajectory, increased risk of carotid injury, technically demanding transseptal puncture, and suboptimal LAA coaxial alignment, necessitating meticulous ultrasound-guided access and continuous transesophageal echocardiographic and fluoroscopic guidance.

Transjugular LAA occlusion is feasible but technically demanding. Individualized procedural planning, meticulous imaging guidance, and operator adaptive techniques are critical determinants of procedural success and optimal patient outcomes.