Recurrent Embolic Stroke after Incomplete Surgical Left Atrial Appendage Closure Managed with Percutaneous Vascular Plug and Coil Embolization

A 74‑year‑old woman with persistent atrial fibrillation and a mechanical mitral valve on warfarin presented with a right hemispheric ischemic stroke treated by mechanical thrombectomy. She had a history of recurrent embolic events during periods of subtherapeutic anticoagulation. Transesophageal echocardiography and ECG‑gated cardiac computed tomography documented a surgically sutured left atrial appendage (LAA) with a residual communication of approximately 3 mm, persistent low intra‑appendage flow with spontaneous echo contrast, a highly mobile filamentous echogenic structure suspicious for thrombus, and severe biatrial dilation. Standard percutaneous LAA occluder devices were considered unsuitable because the residual tract was too small for device deployment. After multidisciplinary discussion, a percutaneous approach was performed under general anesthesia with transesophageal and fluoroscopic guidance. An interventional radiology vascular plug was deployed to occlude the residual communication (VP-II 12 mm), and the LAA cavity was packed with four detachable coils (10-12 mm) to eliminate the low‑flow thrombogenic space. The procedure was completed without immediate complications. Given the presence of a mechanical mitral prosthesis, systemic anticoagulation was continued according to valve requirements; the specific post‑procedural regimen is reported per institutional protocol. Early clinical follow‑up revealed no new neurological events; imaging follow‑up to confirm durable exclusion of the appendage remnant is pending. This case underscores that incomplete surgical LAA exclusion can remain a source of cardioembolism and that combined vascular plug deployment with coil embolization represents a pragmatic alternative when conventional LAAO devices are not feasible.