High-risk pulmonary embolism (PE) represents a life-threatening condition often necessitating urgent intervention. Its management presents challenges, particularly when thrombolysis is contraindicated. Alternative approaches are anticoagulation therapy, mechanical thrombectomy, thromboaspiration and inferior vena cava (IVC) filters. Thromboaspiration, a minimally invasive procedure, has emerged as a promising therapeutic modality, enabling the removal of obstructing thrombi from the pulmonary vasculature, thereby improving hemodynamic stability. This approach offers several advantages, including rapid restoration of pulmonary blood flow, preservation of right ventricular function, and potential avoidance of systemic thrombolysis and its associated risks. The aim of this report is to present a case we treated using the Penumbra’s Indigo® Lightning 12 (PIL 12) aspiration system to treat hemostatic agent’s (Surgiflo®) embolism into right common iliac vein (RCIV), IVC and pulmonary arteries (PA).

A 65-year-old woman with L4-L5 spinal stenosis was admitted for elective spinal surgery involving posterior spinal fusion. The procedure was complicated by haemorrhagic shock during the posterior approach due to a right-sided venous lesion, followed by a 2-minutes cardiorespiratory arrest. To control the bleeding, 4cc of Surgiflo® were injected at the site of bleeding. In the OR, on-table angiography and phlebography were performed, which did not identify any active bleeding but showed compression of the right iliocaval junction by the hemostatic material. A CT angiography (CTA) revealed thrombus in the RCIV and IVC, an active bleeding in the left psoas muscle, and bilateral PE. Patient benefited from arterial embolization in the angiographic suit. Then, thromboaspiration using PIL 12 system was performed into the iliocaval system and into the PA, along with IVC filter placement.

The CTA at 24 hours post-procedure revealed a residual central EP. The angiologic assessment revealed complete recanalization of the iliac thrombosis. The patient was discharged after 12 days with a therapeutic anticoagulation for 3 months.

Thromboaspiration represents a valuable adjunctive strategy in the multifaceted management of PE, allowing for minimal invasive concomitant treatment of deep veinous thrombosis and PE, contributing to improved patient outcomes and enhanced treatment efficacy.