What is the approach to access the femoral vein for pulmonary thrombectomy to remove a pulmonary embolism (PE) from the lungs?

From the Guidelines

To access the lungs for pulmonary thrombectomy via the femoral vein, a percutaneous approach under fluoroscopic guidance is typically used, involving the insertion of a catheter into the femoral vein and advancing it through the inferior vena cava into the pulmonary arteries. The procedure begins with local anesthesia and sterile preparation, followed by the insertion of a catheter into the femoral vein in the groin area. The catheter is then advanced through the inferior vena cava into the right atrium, through the tricuspid valve into the right ventricle, and finally into the pulmonary arteries where the thrombus is located, as described in the 2019 ESC guidelines 1. For catheter-directed thrombolysis or mechanical thrombectomy, specialized devices such as the FlowTriever or AngioJet systems may be used to fragment and remove the clot. During the procedure, contrast dye is injected to visualize the pulmonary vasculature and locate the thrombus, and the patient typically receives anticoagulation therapy before, during, and after the procedure to prevent further clot formation, with options including UFH or the direct thrombin inhibitor bivalirudin 1. This approach is preferred because the femoral vein provides direct access to the venous system leading to the lungs, and its relatively large diameter accommodates the specialized catheters needed for thrombectomy, with a reported procedural success rate of 87% 1. The procedure is generally performed by interventional radiologists or cardiologists with specific training in endovascular techniques. Some key considerations include the use of temporary transvenous pacemaker insertion during rheolytic thrombectomy, and the potential for complications such as death from worsening RV failure, distal embolization, pulmonary artery perforation with lung hemorrhage, and systemic bleeding complications 1. Overall, the choice of approach and devices used may vary depending on the specific clinical scenario and the expertise of the operator.

From the Research

Accessing Femoral Vein for Thrombectomy to Lungs

To access the femoral vein for thrombectomy to the lungs, the following steps can be considered:

• Catheter-directed thrombolysis (CDT) is a highly effective approach in the treatment of deep venous thrombosis (DVT) 2
• The femoral vein can be accessed through a catheter, which can then be guided to the pulmonary arteries for thrombectomy 3
• The use of argatroban and tissue plasminogen activator (tPA) has been shown to be effective in CDT for massive DVT 2
• Mechanical thrombectomy (MT) is also a viable option for treating pulmonary embolism (PE), with similar outcomes to CDT 4

Thrombectomy Procedures

The following thrombectomy procedures can be used to treat PE:

• Catheter-directed thrombolysis (CDT) with tPA and argatroban 2
• Mechanical thrombectomy (MT) using a suction thrombectomy device 3
• Combination of IV tPA and MT for large vessel occlusion (LVO) 5
• Catheter-directed low-dose tPA for treatment of right atrial thrombus caused by a central venous catheter 6

Considerations for Thrombectomy

When considering thrombectomy for PE, the following factors should be taken into account:

• The patient's overall health and medical history 3
• The location and severity of the PE 4
• The potential risks and benefits of each thrombectomy procedure 2, 3, 4
• The availability of experienced medical personnel and equipment 5