Huge Descending Aorta Thrombus in ECPELLA to Durable Left Ventricular Assist Device Recipient Treated With Inari FlowTriever: A Case Report

Thrombotic complications during mechanical circulatory support (MCS) are infrequent but potentially devastating, often presenting prohibitive surgical risks. We report the case of a patient bridged with veno-arterial extracorporeal life support (V-A ECLS) and Impella CP, known as ECPELLA support, to HeartMate 3 left ventricular assist device (LVAD) and subsequent temporary right ventricular assist device (RVAD) implantation for severe biventricular failure. Postoperatively, despite therapeutic anticoagulation, a massive, mobile thrombus, most likely originating during ECPELLA support, was identified in the descending aorta. Given the patient's critical hemodynamic stability on biventricular support and specific contraindications to systemic fibrinolysis (subacute cerebral lesions), open surgical thrombectomy was deemed too high-risk. Consequently, the patient underwent urgent percutaneous mechanical thrombectomy using the Inari FlowTriever system. The procedure, facilitated by a simultaneous, temporary reduction of both LVAD and RVAD flows to stabilize the thrombus position and maximize vacuum efficiency, resulted in the complete removal of a 14 cm thrombus without embolization or hemorrhagic complications. This report demonstrates that catheter-based aspiration thrombectomy can serve as a viable salvage strategy in complex MCS scenarios. It offers a crucial, minimally invasive alternative when conventional surgical and pharmacological options are precluded.