Cerebral-Protected Percutaneous Thrombectomy for Near-Occlusive LVAD Outflow Graft Thrombosis

BACKGROUND: Late low-flow alarms in left ventricular assist devices (LVADs) most commonly result from volume depletion or right-sided failure, but mechanical outflow graft obstruction is an infrequent yet life-threatening cause. CASE SUMMARY: A 70-year-old man with a HeartMate 3 LVAD presented with persistent low-flow (0 L/min) alarms after defecation but felt entirely well. Laboratory testing showed no overt hemolysis, and transthoracic echocardiography excluded right-sided failure. Computed tomographic angiography revealed >90% thrombotic narrowing of the distal outflow graft. The patient underwent percutaneous cerebral-protected thrombectomy with a Penumbra aspiration catheter followed by serial balloon dilatations (8-18 mm) achieving complete graft patency and immediate restoration of device flow to 4 L/min. DISCUSSION: Outflow graft thrombosis occurs in approximately 2% to 5% of contemporary LVAD recipients and carries high morbidity if untreated. Few reports describe successful catheter-directed thrombectomy; this case highlights prompt multimodality imaging, a heart-team approach, and the utility of cerebral protection to mitigate embolic risk. TAKE-HOME MESSAGES: Persistent low-flow alarms mandate systematic evaluation. Early imaging-guided intervention can safely rescue outflow graft thrombosis and avoid emergent pump exchange.