Factors Associated with Successful Thrombus Extraction with the AngioVac Device: An Institutional Experience

Endovascular treatments of acute pulmonary embolism in the post-fibrinolytic era: an up-to-date review

Pulmonary embolism (PE) is a significant contributor to global cardiovascular-related mortality that mainly depends on the severity of the event. The treatment approach for intermediate and high-risk PE remains a topic of debate due to the fine balance between hemodynamic deterioration and bleeding risk. The initial treatment choice for intermediate-risk PE with hemodynamic deterioration and high-risk PE is historically systemic thrombolysis, but this approach is not always effective and carries a notable risk of severe bleeding. For such patients, various interventional treatments have been introduced to clinical practice, including catheter-directed lysis (CDL), ultrasound-assisted CDL, pharmacomechanical CDL, and aspiration thrombectomy. However, the optimal treatment approach remains uncertain. Encouraging outcomes have been presented assessing the novel endovascular treatments, in terms of reducing right ventricular dysfunction and improving hemodynamic stability, opening the possibility of using these devices to prevent hemodynamic instability in less severe cases. However, ongoing randomized trials that assess the efficacy and the association with mortality, especially for aspiration devices, have not yet published their final results. This article aims to offer a comprehensive update of the available catheter-directed therapies for PE, with a focus on novel mechanical thrombectomy techniques, assessing their safety and efficacy, after comparison to the conventional treatment. CRITICAL RELEVANCE STATEMENT: This is a comprehensive review of the indications of use, techniques, and clinical outcomes of the most novel endovascular devices for the treatment of pulmonary embolism. KEY POINTS: Mechanical thrombectomy is an effective tool for patients with PE. Aspiration devices prevent hemodynamic deterioration. Catheter directed therapy reduces bleeding complications.

Suction thrombectomy of a uterine carcinosarcoma tumor thrombus extending into the IVC and right atrium

Uterine carcinosarcoma is a rare, aggressive tumor with several cases in the literature reporting cardiac tumor thrombus involvement. In this case report, we describe a 72-year-old female with a history of uterine carcinosarcoma, who presented with extensive thrombus in the Inferior Vena Cava (IVC) and right atrium. The patient underwent an aspiration thrombectomy which aided in intravascular debulking of the thrombus. Histopathological analysis of the thrombus revealed tumor thrombus. In cryptic cases of tumor thrombus, thrombectomy with histopathological analysis can help confirm the diagnosis of metastatic disease and help guide oncologic staging and further therapy.

Large-Bore Mechanical Thrombectomy of Acute Pulmonary Embolism at a Community-Based Hospital: A Case Series

Acute pulmonary embolism (PE) is a common, and sometimes fatal, diagnosis that results in over 11,000 deaths in hospitalized patients in the USA annually. In patients with high-risk or high-intermediate-risk PE and especially in whom thrombolytic therapy is contraindicated, mechanical thrombectomy can be an effective treatment option. This case series outlines three patients with PE who were successfully treated with large bore aspiration thrombectomy by Interventional Radiology at a community-based military treatment facility (MTF). Two patients had presented to the emergency department with acute PE and a third of patients with acute PE were transferred from an outside hospital specifically for mechanical thrombectomy due to a complication from systemic anticoagulation. The patients were categorized as good candidates for immediate large-bore aspiration thrombectomy, a recently added capability at the MTF. The patients showed immediate improvement post-procedure and required only one night admission for observation to the intensive care unit. Implementation of this new capability for patients with acute high-risk or high-intermediate-risk PE or with contraindications to thrombolysis provides an alternative treatment with immediate, life-saving capability.

Aspiration of Right Sided Intracardiac Masses in High-Risk Surgical Patients Using AngioVac: A Case Series and Review of Literature

Management of large right heart thrombi and vegetations is challenging. Medical management may be insufficient to prevent embolization or treat infection. Surgery carries a high mortality and is often not an option for these patients with multiple comorbidities. We present a case series of four patients describing percutaneous aspiration thrombectomy with AngioVac device as a safe and effective treatment for high-risk patients with right heart thrombi or tricuspid valvular vegetations. Indexing words.

Catheter-Directed Thrombolysis or Catheter-Based Thrombectomy in Acute Pulmonary Embolism: Horses for Courses

Venous thromboembolism is a common disorder encompassing both pulmonary embolism (PE) and deep vein thrombosis (DVT). In the United States, up to 2 million people are diagnosed with DVT and 600,000 with PE annually. The purpose of this review is to discuss the indications and evidence for catheter-directed thrombolysis versus catheter-based thrombectomy.

Percutaneous Management of High-Risk Pulmonary Embolism

Acute pulmonary embolism (PE) leads to an abrupt increase in pulmonary vascular resistance and right ventricular afterload, and when significant enough, can result in hemodynamic instability. High-risk PE is a dire cardiovascular emergency and portends a poor prognosis. Traditional therapeutic options to rapidly reduce thrombus burden like systemic thrombolysis and surgical pulmonary endarterectomy have limitations, both with regards to appropriate candidates and efficacy, and have limited data demonstrating their benefit in high-risk PE. There are growing percutaneous treatment options for acute PE that include both localized thrombolysis and mechanical embolectomy. Data for such therapies with high-risk PE are currently limited. However, given the limitations, there is an opportunity to improve outcomes, with percutaneous treatments options offering new mechanisms for clot reduction with a possible improved safety profile compared with systemic thrombolysis. Additionally, mechanical circulatory support options allow for complementary treatment for patients with persistent instability, allowing for a bridge to more definitive treatment options. As more data develop, a shift toward a percutaneous approach with mechanical circulatory support may become a preferred option for the management of high-risk PE at tertiary care centers.

Catheter-Directed Interventions for the Treatment of Lower Extremity Deep Vein Thrombosis

Lower extremity deep vein thrombosis (DVT) leads to significant morbidity including pain, swelling, and difficulty walking in the affected limb. If left untreated, DVT increases the risk of pulmonary embolism (PE), recurrent venous thromboembolism (VTE), and post thrombotic syndrome (PTS). The objective of this review was to identify catheter-directed interventions and their success rates for the treatment of lower extremity DVT. A comprehensive search of current and emerging catheter-directed interventions for lower extremity DVT treatment was conducted in PubMed and Google Scholar. Clinical trials, retrospective and prospective observational studies, and case reports were identified to classify percutaneous mechanical thrombectomy (PMT), catheter-directed thrombolysis (CDT), and pharmacomechanical CDT (PCDT) devices based on their mechanism of action and indication of use. Catheter-directed interventions such as PMT, CDT, and PCDT offer an alternative therapeutic strategy for DVT management, particularly in patients with limb-threatening conditions and absolute contraindications to anticoagulants. Currently, there are limited guidelines for the use of mechanical and pharmacomechanical devices because of the lack of clinical evidence available for their use in treatment. Future studies are required to determine the short and long-term effects of using catheter-directed interventions as well as their effectiveness in treating acute versus subacute and chronic DVT.

Right Heart Clot-in-Transit: Endovascular Therapies

Right heart thrombus is a challenging high mortality disease typically seen in the setting of pulmonary embolism. Traditional treatments have included anticoagulation, thrombolysis, and surgical embolectomy. Advances in recognition and treatment of clot-in-transit have led to the development of endovascular therapies increasingly becoming the preferred method of treatment due to rapid debulking and lower morbidity. Novel endovascular devices are large bore aspiration thrombectomy systems which mitigate the use of concomitant thrombolytics. The article reviews the disease process, relevant literature, and current endovascular devices and strategies for the treatment of right heart thrombus and clot-in-transit.

Percutaneous Large Thrombus and Vegetation Evacuation in the Catheterization Laboratory

Intracardiac and intravascular thrombi are associated with significant morbidity and mortality. Although surgery remains the gold standard treatment option, these patients often have multiple comorbidities that can make surgical options challenging. With advancements in catheter-based technologies, there are now percutaneous treatment options for these patients. The AngioVac is a percutaneous vacuum-assisted thrombectomy device FDA-approved for removal of intravascular debris that uses a venovenous extracorporeal membranous oxygenation circuit with a filter. Use of this device has now been reported in the removal of right atrial or iliocaval thrombi, debulking tricuspid vegetations, removal of vegetations from implantable cardiac devices, and pulmonary embolism.

Pulmonary Embolism and Pregnancy-Challenges in Diagnostic and Therapeutic Decisions in High-Risk Patients

Diagnosis of acute PE in pregnant women with haemodynamic instability is following the general integrated risk-adapted diagnostic algorithm and starts with bedside echocardiography to assess RV function. If RV dysfunction is identified, a prompt and immediate reperfusion without further imaging should be initiated. Although pregnancy is listed as a relative contraindication of systemic thrombolysis, in pregnant women with acute PE and haemodynamic instability thrombolysis must be considered. In those cases, other treatment strategies as surgical embolectomy or catheter-directed low-dose thromboylysis or percutaneous thrombectomy should be taken into consideration as well. A multidisciplinary team with experience of PE management in pregnancy should be consulted to reach consensus on the best treatment approach.

A Novel Technique Debulking Vegetations in Tricuspid Endocarditis and Venacava Utilizing AngioVac Aspiration System

The AngioVac system (AngioDynamics Inc., Latham, NY) is used for the removal of commonly encountered intravascular material, such as thrombus or vegetations in the right atrium, right ventricle, superior vena cava, and inferior vena cava. Patients with high surgical risk having tricuspid endocarditis and superior vena cava thrombus can be treated with the AngioVac system, hence mitigating the risks for this patient population. We present a case series with the utilization of the AngioVac device to reduce the vegetation size and decrease the risk of emboli with effective antibiotic penetration. Transesophageal echocardiography shows a reduction in the size of the vegetations in all three cases with no postoperative complications. This case series demonstrates a novel technique debulking vegetations in tricuspid endocarditis and vena cava.

AngioVac for Minimally Invasive Removal of Intravascular and Intracardiac Masses: a Systematic Review

PURPOSE OF REVIEW

Management of intracardiac masses, such as right heart thrombi and catheter-related vegetations, can be challenging. Many patients are high-risk candidates for surgical extraction due to multiple comorbidities and risk of distal embolization. In this review, we highlight the advancements in percutaneous approaches for treatment of intracardiac masses utilizing AngioVac (AngioDynamic, Latham, NY).

RECENT FINDINGS

With the Food and Drug Administration (FDA) approval of the AngioVac System in 2009, a growing body of evidence has proven it to be a feasible and effective tool to extract thrombi and masses from the iliocaval system and the right heart. In this review, we highlight the feasibility of AngioVac System (AngioDynamic, Latham, NY) based on the published cases series and registries. Future randomized controlled trials are needed to establish an algorithmic approach in treating intracardiac masses.

Right Atrial Thrombi, the Management Conundrum: 2 Case Reports

Case series

Patients: Male, 62-year-old • Male, 66-year-old

Final Diagnosis: Right atrial floating thrombus • right heart thrombus-in-transit

Symptoms: Shortness of breath

Medication: —

Clinical Procedure: —

Specialty: Cardiology

Successful IVC thrombus extraction with the AngioVac device following five vessel coronary artery bypass graft: a case report

Background

Inferior vena cava thrombosis is cited to be a complication of inferior vena cava filter placement and post coronary artery bypass surgery. Often only mild symptoms arise from these thrombi; however, due to the chronic nature of some thrombi and the recanalization process, more serious complications can arise. Although anticoagulation remains the gold standard of treatment, some patients are unable to be anticoagulated. In this case, we present a 65-year-old male who underwent IVC filter placement and open-heart surgery who later developed extensive femoral and iliocaval thrombosis leading to right heart failure, which required thrombus extraction with an AngioVac suction device.

Case presentation

We present a 65-year-old male who presented with bilateral pulmonary emboli with extensive right lower extremity deep vein thrombosis. Upon investigation he had ischemic heart disease and underwent a five-vessel coronary artery bypass for which he had an IVC filter placed preoperatively. On post operative day 3 to 4, he was decompensated and was diagnosed with an IVC thrombus. He progressed to right heart failure and worsening cardiogenic shock despite therapeutic anticoagulation and was taken for a suction thrombectomy using the AngioVac (AngioDynamics, Latham, NY) aspiration thrombectomy device. The thrombectomy was successful and he was able to recover and was discharged from the hospital.

Conclusion

Despite being a rare complication, IVC thrombosis can have detrimental effects. This case is an example of how IVC thrombus in the post-operative setting can lead to mortality. The gold standard is therapeutic anticoagulation but despite that, this patient continued to have worsening cardiogenic shock. Other therapies have been described but because of its rarity, they are only described in case reports. This case shows that the AngioVac device is a successful treatment option for IVC thrombus and can have the possibility of future use.

Hybrid repair for acute aortic occlusion using aortobifemoral bypass and AngioVac thrombectomy

Aortic thrombus with multilevel acute ischemia is rare. We report the use of vacuum-assisted thrombectomy of an aortic mural thrombus with superior mesenteric artery involvement causing bilateral lower extremity ischemia and acute mesenteric ischemia, in conjunction with embolectomy and fasciotomy. We describe the novel use of the AngioVac device (AngioDynamics, Latham, NY) for reperfusion in the systemic arterial circulation. This case report demonstrates a feasible and less invasive alternative to the management of aortic thrombi with acute ischemia in patients unfit for open aortic thrombectomy of the visceral segment aorta.

Perioperative Outcomes of Thrombectomy Patients Using Venovenous Bypass and Suction Filtration With General Anesthesia

OBJECTIVE

AngioVac (Angiodynamics, Latham, NY) is a novel drainage system that offers a less-invasive approach compared with open surgical thromboembolectomy to remove intracardiac and intravascular thrombotic and embolic material. For this study, the authors' single-center experience with patients undergoing thromboembolectomy using the AngioVac system was reviewed retrospectively to evaluate anesthetic management and postoperative complications.

DESIGN

Retrospective, observational study.

SETTING

Single institution, quaternary care hospital.

PARTICIPANTS

The study comprised 20 consecutive patients whose treatment included the AngioVac between January 2016 and November 2019.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Twenty patients underwent AngioVac suction filtration. The mean age was 56 years, and women comprised 35% of the patient cohort. Indications for AngioVac suction filtration included deep venous thrombosis involving the inferior vena cava (n = 12 [60%]), right atrial mass/thrombus (n = 11 [55%]), right ventricular mass/thrombus (n = 3 [15%]), and pulmonary embolism(n = 2 [10%]). All patients required vasopressor support, and nine patients (45%) required blood transfusion during the procedure. There was no intraoperative death or cardiac arrest associated with the procedure. The 30-day mortality was zero, and in-hospital mortality was 5% (1/20). Significant postoperative complications occurred in 11/20 patients (55%). Postoperative left ventricular dysfunction (36% v 0%; p < 0.05), preoperative shock requiring vasopressors (36% v 0%; p < 0.05), postoperative blood transfusion (100% v 56%; p < 0.05), and having undergone recent surgery (64% v 11%; p < 0.05) were associated with increased odds of experiencing postoperative complications.

CONCLUSIONS

The rate of intraoperative complication during AngioVac suction filtration is low, but vasopressors and blood transfusions often are required. Patients at increased risk of developing postoperative complications potentially can be identified as having undergone recent surgery, experiencing preoperative shock requiring vasopressors or postoperative left ventricular dysfunction, and requiring postoperative blood transfusion.

Catheter-based embolectomy prior to right ventricular mechanical circulatory support placement after heart transplantation

Severe acute isolated right ventricular failure has limited dedicated percutaneous temporary mechanical circulatory support options, especially after orthotopic heart transplantation. The advent of the Impella RP device provides a newer option, though an absolute contraindication to device placement is thrombus within the right heart. We present a novel case where catheter-based embolectomy was used to evacuate right heart thrombus before Impella RP placement in a patient with severe acute right ventricular failure due to primary graft dysfunction after orthotopic heart transplantation.

Technical implementation of percutaneous thrombus aspiration using the AngioVac system

OBJECTIVES

The AngioVac system (AngioDynamics, Latham, NY, USA) provides a method for the minimally invasive, percutaneous aspiration of thrombus formations originating from the central venous system as well as solid matter such as lead vegetations and right atrial thrombi.

METHODS

This retrospective, observational study describes the initial experience in 52 adult patients with the AngioVac system, focusing mainly on the development of the extracorporeal circuit to improve usability and safety.

RESULTS

The mean patient age was 62.9 years (range 23-86 years). 22 patients were female and 30 were male. Indications for percutaneous aspiration were lead vegetations (n = 36; 69.2%), right atrial thrombi (n = 9; 17.3%), central venous thrombi (n = 5; 9.6%) and pulmonary embolisms (n = 2; 3.8%). Successful aspiration was performed in 44 cases (84.6%) and partial success was achieved in five patients (9.6%), while failure to remove thrombi or vegetations occurred in three cases (5.8%). Our practical experience led to the installation of a shunt line for recirculation and the implementation of safety features concerning air handling, which are also employed in minimally invasive extracorporeal bypass circuits. Initial tests monitored the level of negative pressure according to differences in flow and access sites but these still have to be validated on a larger scale.

CONCLUSION

In this initial experience, the AngioVac system appeared to be safe regarding the extracorporeal circulation and the elimination of thrombi and lead vegetations.

Saved by the VAC: Minimally Invasive Removal of a Surely Fatal Right Heart Thrombus in a Patient with Advanced Heart Failure

Intracardiac thrombi are associated with an increased morbidity and mortality due to their unpredictability and embolic potential. Right heart thrombus is infrequently encountered in clinical practice outside the scenario of acute pulmonary embolism with hemodynamic compromise, and even more uncommon is the presence of a massive right heart thrombus. Embolic potential is high, and historically, management has revolved around open surgical removal or systemic thrombolysis. We hereby present a case of a massive right heart thrombus in a high surgical risk patient, which was successfully removed using a percutaneous aspiration device.

Transesophageal echocardiography guidance for atrial-caval thrombus removal with the AngioVac system

Thromboembolectomy is often guided with fluoroscopy. For intracardiac and great vessel thromboemboli, transesophageal echocardiography (TEE) can assess these thrombi, guide precise suction catheter placement, prevent intracardiac injury, and serve as a hemodynamic monitor. TEE can also be used to assess blood flow and thrombotic material reduction following embolectomy. TEE is a low-risk, high-value, real-time imaging modality that facilitates thromboembolectomy and increases patient safety.

Noteworthy Cardiac Surgical Literature 2018: Value-Based Bundled Payments, Opioid Crisis and Cardiac Surgery, Percutaneous Suction Thrombectomy for Intracardiac/Caval Thrombus and Vegetations, and Minimally Invasive Left Ventricular Assist Device Placement

There has been tremendous evolution in the care of cardiac surgical patients in 2018. In this article, 4 topics of considerable impact on cardiac surgical care in the current landscape are reviewed based on recent publications. The first topic reviews the recent paradigm shift to value-based payments and the potential role of bundled payments on health care and physician reimbursement. The second topic highlights the impact of the opioid crisis on cardiac surgery. The third topic demonstrates the increasing utilization and expanding role of novel percutaneous suction thrombectomy technique in the extraction of caval and right-sided intracardiac thrombi and vegetations with veno-venous bypass. The final topic reviews the current trend of minimally invasive left ventricular assist device placement. Each of these topics addresses the contemporary issues in cardiac surgery with the reasoning for evolution in our current practices in 2018.

Effect of Percutaneous Suction Thromboembolectomy on Improved Right Ventricular Function

Venous thromboembolism is a leading cause of cardiovascular death. Historically, surgical intervention has been associated with high morbidity rates. Pharmacologic therapy alone can be inadequate for patients with substantial hemodynamic compromise, so minimally invasive procedures are being developed to reduce clot burden. We describe our initial experience with using the AngioVac system to remove thromboemboli percutaneously. We reviewed all suction thromboembolectomy procedures performed at our institution from March 2013 through August 2015. The main indications for the procedure were failed catheter-directed therapy, contraindication to thrombolysis, bleeding-related complications, and clot-in-transit phenomena. We collected details on patient characteristics, procedural indications, thrombus location, hemodynamic values, cardiac function, pharmacologic support, and survival to discharge from the hospital. The Wilcoxon signed-rank test was used for statistical analysis. Thirteen patients (mean age, 56 ± 15 yr; 10 men) underwent suction thromboembolectomy; 10 (77%) survived to hospital discharge. The median follow-up time was 74 days (interquartile range [IQR], 23-221 d). Preprocedurally, 8 patients (62%) had severe right ventricular dysfunction; afterwards, 11 (85%) had normal function or mild-to-moderate dysfunction, and only 2 (17%) had severe dysfunction (P=0.031). Percutaneous suction thromboembolectomy, a promising therapeutic option for patients, appears to be safe, and we found it to be associated with improved right ventricular function.

Endovascular therapy for acute severe pulmonary embolism

Acute pulmonary embolism (PE) is a major public health problem and accounts for 100,000-180,000 deaths per year in the United States. Current prognostic stratification separates acute PE into massive, submassive, and low-risk by the presence or absence of sustained hypotension, RV dysfunction, and myocardial necrosis. Massive, submassive and low-risk PE have mortality rates of 25-65%, 3%, and < 1%, respectively. In this review we will focus on therapies currently available to manage acute massive and submassive PE.

Thrombectomy and thrombolysis for the prevention and treatment of postthrombotic syndrome

Postthrombotic syndrome (PTS) is a frequent complication of lower-extremity deep vein thrombosis (DVT), occurring in approximately 40% of patients despite the use of anticoagulant therapy. PTS causes significant impairment of patients' health-related quality of life, and no evidence-based therapies have been consistently effective. Catheter-directed thrombolysis and thrombectomy have been shown to remove acute thrombus, and it has been hypothesized they could prevent or reduce PTS. However, because these procedures can be associated with complications, mainly bleeding, randomized trial data are needed to determine when they should be used. In this article, I summarize the current status of thrombus removal procedures for DVT to provide contemporary guidance to clinicians seeking to individualize treatment decisions for their patients.

Advanced Cardiopulmonary Support for Pulmonary Embolism

Management of high-risk pulmonary embolism (PE) requires an understanding of the pathophysiology of PE, options for rapid clot reduction, critical care interventions, and advanced cardiopulmonary support. PE can lead to rapid respiratory and hemodynamic collapse via a complex sequence of events leading to acute right ventricular failure. Importantly, reduction in pulmonary vascular resistance must be accomplished either by systemic thrombolytics, catheter directed thrombolytics, endovascular clot extraction, or surgical embolectomy. There are important advances in these techniques all of which have a niche role in the cardiopulmonary stabilization of critically ill patient with PE. Critical care support surrounding the above interventions is necessary. Maintenance of systemic perfusion and cardiac output may require careful titration of vasopressors, inotropes, and preload. Extreme caution should be taken with approach to intubation and positive pressure ventilation. A hemodynamically neutral induction with preparations for circulatory collapse should be the goal. Once intubated, the effect of positive pressure on pulmonary vascular resistance and right ventricular hemodynamics is necessary. Veno-arterial extra corporeal membrane oxygenation plays an increasingly important role in the stabilization of the hemodynamically collapsed patient who either has a contraindication to systemic lytics, failed systemic lytics, or requires a bridge to surgical or catheter embolectomy. Veno-arterial extra corporeal membrane oxygenation has also been used alone to stabilize the circulation until hemodynamics normalize on anticoagulation and has also been used in tenuous patient as a safety net for endovascular procedures.