Rescue catheter directed treatment for floating right atrial thrombi and deep vein thrombosis in patient with high-risk acute pulmonary embolism: a case report of multidisciplinary approach

High-risk pulmonary embolism (PE) complicated by floating right atrial thrombi (RAT) carries a significantly increased mortality risk, often requiring urgent intervention beyond systemic thrombolysis (ST). However, current guidelines lack specific recommendations for managing persistent RAT following ST. Catheter-directed therapies (CDTs) have emerged as a promising alternative in this setting. We report a novel single-session, multidisciplinary approach combining mechanical thrombectomy of both RAT and iliofemoral deep vein thrombosis (DVT) using the Penumbra Indigo Lightning System.

A 74-year-old woman presented with syncope and signs of cardiogenic shock. Imaging confirmed high-risk PE with floating RAT and extensive iliofemoral DVT. Initial treatment with ST led to partial haemodynamic recovery but persistent RAT. A multidisciplinary Pulmonary Embolism Response Team elected to perform percutaneous thrombectomy. Under transoesophageal echocardiography and fluoroscopic guidance, mechanical aspiration of the right atrial thrombus was successfully performed using the Penumbra Indigo Lightning 12 F catheter. In the same session, intravascular ultrasound-guided aspiration of iliofemoral DVT was achieved, with confirmation of complete thrombus removal and exclusion of the May–Thurner syndrome. The patient had an uneventful recovery, with restored right ventricular function and no recurrent thromboembolism or post-thrombotic syndrome at follow-up.

This case demonstrates the feasibility and safety of a combined single-session catheter-directed approach for simultaneous treatment of RAT and DVT following ST failure. The integration of multidisciplinary decision-making, advanced aspiration technology, and intravascular imaging may optimize outcomes in complex PE cases and supports expanding the role of CDTs in rescue settings.