Massive pulmonary embolism (PE) is a life-threatening condition caused by the obstruction of pulmonary arteries requiring precise and timely intervention to prevent mortality.

Clots in transit (CIT), which are thrombi traveling through the right heart, pose a unique challenge due to their high risk of embolization to the pulmonary arteries.

The treatment of massive PE, particularly in the presence of CIT, demands careful consideration of the patient’s clinical status and contraindications to standard therapies like thrombolysis.

In this case, we present the use of fluoroscopy and transthoracic echocardiography (TTE) for real-time guidance during large-bore mechanical thrombectomy (LBMT) to remove right ventricle (RV) thrombi.

This case demonstrates the importance of TTE in guiding LBMT, offering minimally invasive and effective treatment for high-risk CIT patients.

TTE’s real-time imaging capabilities and noninvasive nature make it a valuable tool in critically ill patients, particularly when sedation for TEE is contraindicated.

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