Table 1: Comparison between three cases where EKOS was used for treatment of a right atrial thrombus.

CaseShammas et al. [10]Nickel et al. [9]Our case



Risk factors for thrombosisLimited activity
(familial spastic paraparesis)
Metastatic melanoma
IVC filter
Prostate cancer

Thrombus size2.8 × 2.3 cm8.2 × 4.1 cm8.4 × 0.5 cm

Attachment Interatrial septumA thin attachment to the cavoatrial junction in the region of IVC stent (large volume thrombosis extending from the femoral veins bilaterally, into the vena cava and proximal right atrium)Along anterolateral Rt atrium

Mobility Mobile MobileHighly mobile

Prolapsing into RVNoYesYes

Presence of PEBilateral extensive PE with near occlusion of Rt main trunk and nonocclusive thrombus at left PAChronic PE with mildly enlarging emboli in the left main and right posterior segmental pulmonary arteries (status post-prior IVC filter placement)No

Vitals on admissionSBP 80, HR 120, 98% 5-6-liter NCN/A95/60, 97, 97%

EKOS catheter24 cm and 12 cmN/A12 cm/135

Site of EKOS catheter(24) junction between RA and IVC into Rt main PA extending into the thrombus
(12) through Rt CFV to left PA
N/AInto the right atrium and the right ventricle

Thrombolytic typetPAAlteplaseAlteplase

Duration12 hrs24 hrs, then 48 hrs10 hrs

Dose24 mg total
(1 mg/hr for 12 hours each total 24 mg)
48 mg total
(1 mg/hr for 24 hours, then 0.5 mg/hr for 48 hours)
25 mg total,
5 mg bolus,
then 2 mg/hr

EKOS accessBilateral CFVsPopliteal veinsLeft subclavian vein

Outcomes(i) Echo postprocedure immediately: Rt atrial thrombus not dislodged
(ii) Echo 24 hours later: complete resolution of Rt atrial thrombus
(iii) CTA: marked improvement of Rt PA thrombus and lt PA
(i) Venography: grade III lysis in the pelvic
veins (99-100%), with residual occlusive thrombus in the suprarenal IVC, superior to the filter, extending to the cavoatrial junction
(ii) After 48 hrs of reinitiated EKOS: persistent filling defect in the suprarenal IVC
(iii) Venoplasty was done with extrusion of the cavoatrial filling
defect into the right atrium. Managed with Angiovac
Resolution of the thrombus (continued on warfarin)

Other modalities used24 hrs of heparin, then rivaroxabanHeparin
Endovascular retrieval using the Vortex Angiovac system (AngioDynamics, Marlborough, MA)
Heparin, then warfarin