Percutaneous Extraction of a Large Device Related Thrombus on a Watchman™ Device: A Case Report

Background Left atrial appendage occlusion devices are commonly used to prevent stroke in patients with persistent atrial fibrillation who are unable to tolerate anticoagulation. However certain patient and device related characteristics increase the risk for the development of a device related thrombus. The presence of a device related thrombus increases the risk of stroke and should be treated. Management of device related thrombus lacks consensus but is mostly focused on anticoagulation. In patients with large thrombi that need to be managed urgently, percutaneous extraction may be a viable option. Case Summary In this report we describe the successful management of a device related thrombus via percutaneous thrombus extraction technology in an 81-year-old woman with a large thrombus attached to a WATCHMAN™ device. The patient initially presented with shortness of breath, and on imaging a pedunculated thrombus was detected. The thrombus was extracted using a Penumbra Lightning 12™ (Penumbra Inc., Alameda, CA) catheter with a Sentinel™ (Boston Scientific, Marlborough, Massachusetts) cerebral embolic protection device. The patient had no neurologic sequelae and was started on anticoagulation. Discussion Percutaneous thrombectomy can be safely performed to extract large left atrial occlusion device related thrombus that require urgent management, without any neurologic sequelae. We believe this can be used in patients with a large device related thrombus who would not be adequately managed with anticoagulation and in whom surgery is not feasible.

Percutaneous treatment of a huge patent ductus venosus and severe portal vein hypoplasia using a Figulla Flex ll ASD-occluder in a two-year-old infant: a case report

Background Intra- or extrahepatic porto-caval shunts can account for multiorgan dysfunction with pulmonary arterial hypertension and portosystemic encephalopathy as the most serious consequences of bypass of the hepatic circulation. The ductus venosus represents a rare Foetal porto-caval shunt and might be persistently patent in newborns after birth. Treatment strategies include surgical ligation and percutaneous device closure. The degree of portal vein hypoplasia limits therapy making liver transplantation the only option in some of them. Case summary In a newborn female patient a huge persistently patent ductus venosus, known already prenatally, resulted in severe secondary portal vein hypoplasia. She presented with hyperammonemia, elevated liver enzymes and pulmonary hypertension. With only diminutive portal venous branches and exceedingly high portal venous pressures during test-occlusion of the ductus venosus, shunt closure was not possible. At the age of two years more favorable portal venous pressures allowed transcatheter device closure with a nitinol ASD-occlusion device. Pulmonary artery pressures and ammonia levels normalized after the procedure without any signs of portal hypertension. Discussion The case highlights the importance of meticulous imaging using balloon occlusion angiography of porto-caval shunts like the ductus venosus, to search for intrahepatic portal veins. Moreover, portal vein pressure during test-occlusion can identify patients amenable for surgical or endovascular shunt closure. Occlusion devices licensed for other indications like atrial septal defect closure can be used safely in huge porto-caval shunt vessels in a one-step or staged procedure. Optimal timing of the intervention should be tailored to the patient’s needs

Local 3-Dimensional Printing of a Calvarium-Anchored Ventricular Catheter Occlusion Device

ABSTRACT Three-dimensional (3D)-printed objects have been incorporated into many surgical specialties for various purposes. These devices can be customized and used as implants or surgical instruments. This study describes the use of a 3D-printed device that eliminates the need for a surgical assistant to occlude and retain the intracranial catheter during ventriculoperitoneal shunt creation and revision. After we identified design considerations and solutions, we modeled the device dimensions using computer-aided design software. Prototypes were 3D printed using stereolithography. Iterative design improvements were tested on cadaveric cranial samples. A final design was established, prepared by the in-hospital sterile processing department, and deployed successfully for clinical use. The design process for 3D-printed surgical instruments can produce straightforward idea-to-prototype pipelines. Because 3D-printed devices are easily duplicated and modified, small adjustments and new models can be developed, printed, and tested in a short time span.