Left atrial appendage closure device implantation via transhepatic vascular access: a case report

Background In patients with non-valvular atrial fibrillation, an estimated 90% of thrombi are located in the left atrial appendage. The WATCHMAN device is a left atrial appendage closure device that is an alternative therapeutic option to reduce the risk of systemic embolization in patients who are intolerant of long-term oral anticoagulation. It can be deployed in the left atrial appendage using a transseptal approach via the femoral vein. Transhepatic venous access is an alternative route for the delivery of the device in a patient with difficult vascular access. Case summary An 81-year-old man with persistent non-valvular atrial fibrillation, heart failure with reduced ejection fraction (HFrEF), and diabetes mellitus was deemed a poor candidate for anticoagulation due to recurrent falls and gastrointestinal bleeding. He was selected for a left atrial appendage closure. The initial procedure was aborted after significant resistance to device advancement was encountered in the right femoral vein. Lower extremity venography demonstrated totally occluded femoral and iliac veins bilaterally. The decision was made to implant the device via a transhepatic approach. The procedure had no complications and the patient was discharged on rivaroxaban and aspirin after 3 days. Discussion Transhepatic venous access is a viable option in patients with poor femoral access for implantation of the WATCHMAN device. It can be done safely. Knowledge of this procedural alternative can greatly enhance patient care.