Massive pulmonary embolism (PE) is a cardiovascular emergency with high morbidity and mortality. We present a case of massive PE successfully managed using a fully percutaneous approach guided by multimodal imaging and treated with the INARI® FlowTriever system.

A patient with acute dyspnea, hypotension, and severe hypoxemia underwent computed tomography (CT) pulmonary angiography, which revealed an extensive thrombus burden and right ventricular overload (Figure 1). Intravascular ultrasound imaging revealed organized thrombus within the pulmonary arteries (Figure 1), while pulmonary angiography and CT showed near-complete occlusion of the right pulmonary artery (Figure 2A and B).

Figure 1.

Further illustrates the integration of multimodal imaging in diagnosis and procedural planning, showing sequential IVUS slices correlated to CT and angiographic anatomy. This approach enabled precise thrombus localization and device navigation.

Figure 2.

(A) Angiography demonstrating thrombus. (B) Thrombus burden in computed tomography imaging. (C) Imaging showing aspiration device. (D) Schematic representation of aspirated thrombus burden in the right pulmonary artery.

Intravascular ultrasound imaging provides enhanced visualization of the pulmonary artery, enabling better anatomical identification and characterization of thrombi – essential information for guiding therapeutic decisions. Furthermore, it can reduce unsuccessful aspirations by helping to accurately position the aspiration catheter. Despite the restricted visualization of the pulmonary tree, multimodal imaging effectively guides the intervention.

Despite limited visualization of the pulmonary tree, multimodal imaging effectively guides the intervention. The INARI® FlowTriever system allowed safe and effective aspiration of large, cohesive thrombotic material (Figure 2C), which exhibited striking anatomical resemblance to the pulmonary arterial tree upon extraction (Figure 2D). The retrieved clot confirmed extensive proximal embolization, consistent with pre-procedural imaging.

Following the intervention, hemodynamic parameters improved significantly, with a rapid normalization of oxygen saturation and right ventricular function on echocardiography.

This case highlights the efficacy of catheter-directed thrombectomy using the INARI® system in treating massive PE, especially when thrombolytics are contraindicated, multimodal imaging plays a crucial role in patient selection, procedural guidance, and outcome assessment.