Early Experience with AngioVac Aspiration in the Pulmonary Arteries

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.

Percutaneous interventions for pulmonary embolism

Pulmonary embolism (PE) ranks as a leading cause of in-hospital mortality and the third most common cause of cardiovascular death. The spectrum of PE manifestations varies widely, making it difficult to determine the best treatment approach for specific patients. Conventional treatment options include anticoagulation, thrombolysis, or surgery, but emerging percutaneous interventional procedures are being investigated for their potential benefits in heterogeneous PE populations. These novel interventional techniques encompass catheter-directed thrombolysis, mechanical thrombectomy, and hybrid approaches combining different mechanisms. Furthermore, inferior vena cava filters are also available as an option for PE prevention. Such interventions may offer faster improvements in right ventricular function, as well as in pulmonary and systemic haemodynamics, in individual patients. Moreover, percutaneous treatment may be a valid alternative to traditional therapies in high bleeding risk patients and could potentially reduce the burden of mortality related to major bleeds, such as that of haemorrhagic strokes. Nevertheless, the safety and efficacy of these techniques compared to conservative therapies have not been conclusively established. This review offers a comprehensive evaluation of the current evidence for percutaneous interventions in PE and provides guidance for selecting appropriate patients and treatments. It serves as a valuable resource for future researchers and clinicians seeking to advance this field. Additionally, we explore future perspectives, proposing "percutaneous primary pulmonary intervention" as a potential paradigm shift in the field.

Large Saddle Pulmonary Embolism Safely Managed by Ultrasonic-supported Catheter-directed Thrombolytic Therapy

A 40-year-old patient confirmed on computed tomography of the pulmonary arteries (CT/PAs) a large saddle pulmonary embolus in the main PA extending in both branches. He was managed by ultrasound-supported catheter-directed (EkoSonic, Boston Scientific) intrapulmonary thrombolytic therapy using a recombinant tissue plasminogen activator prolonged infusion over 16 h with a total dose of 50 mg divided in both PAs simultaneously with intravenous unfractionated heparin. He showed clinical improvement with improved arterial oxygen (PaO2) with reduced oxygen therapy with a nasal cannula. Follow-up right heart catheterization showed a significant reduction of PA pressure from 96/32 (mean 64) to 47/27 (mean 39) mmHg. Repeat pulmonary angiography showed significant improvement in PA branch opacification, suggesting increased flow and successful therapy. The patient received oral anticoagulants for months. He had followed with CT/PA and echocardiogram after 4 weeks, both were normalized. He resumed his regular physical activities, including exercises in the gymnasium.

Role of Intravascular Ultrasound in Pulmonary Embolism Patients Undergoing Mechanical Thrombectomy: A Systematic Review

BACKGROUND

Traditionally, mechanical thrombectomy performed for pulmonary embolism (PE) necessitates the utilization of iodinated contrast. Intravascular ultrasound (IVUS) has been used as a diagnostic and therapeutic modality in the management of acute high and intermediate-risk PE. Recently, with the shortage of contrast supplies and the considerable incidence of contrast-induced acute kidney injury (CI-AKI), other safer and more feasible IVUS methods have become desirable. The purpose of this systematic review was to evaluate the importance of IVUS in patients with PE undergoing thrombectomy.

METHODS

Medline/PubMed, Embase, Scopus, and Google Scholar were searched for review studies, case reports, and case series. Clinical characteristics, outcomes and the usage of IVUS-guided mechanical thrombectomy during the treatment of acute high and intermediate-risk PE were examined in a descriptive analysis.

RESULTS

In this systematic review, we included one prospective study, two case series, and two case reports from July 2019 to May 2023. A total of 39 patients were evaluated; most were female (53.8%). The main presenting symptoms were dyspnea and chest pain (79.5%); three patients (7.9%) presented with syncope, one with shock and one with cardiac arrest. Biomarkers (troponin and BNP) were elevated in 94.6% of patients. Most patients (87.2%) had intermediate-risk PE, and 12.8% had high-risk PE. All patients presented with right-heart strain (RV/LV ratio ≥ 0.9, n = 39). Most patients (56.4%) had bilateral PE. Mechanical thrombectomy was performed using IVUS without contrast utilization in 39.4% of the patients. After the initial learning curve, contrast usage decreased gradually over time. There was a significant decrease in the composite mean arterial pressure immediately following IVUS-guided thrombectomy from 35.1 ± 7.2 to 25.2 ± 8.3 mmHg (p < 0.001). Post-procedure, there was no reported (0%) CI-AKI, no all-cause mortality, no major bleeding, or other adverse events. There was a significant improvement in symptoms and RV function at the mean follow-up.

CONCLUSIONS

New evidence suggests that IVUS-guided mechanical thrombectomy is safe, with visualization of the thrombus for optimal intervention, and reduces contrast exposure.

Unmet Needs and Future Direction for Pulmonary Embolism Interventions

Venous thromboembolism (VTE) usually develops in the deep veins of the extremities. Pulmonary embolism (PE) is a type of VTE that is most commonly (∼90%) caused by a thrombus that originates from the deep veins of the lower extremities. PE is the third most common cause of death after myocardial infarction and stroke. In this review, the authors investigate and discuss the risk stratification and definitions of the aforementioned categories of PE and further explore the management of acute PE along with the types of catheter-based treatment options and their efficacy.

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.

Contemporary interventional management of pulmonary embolism

Minimally invasive interventional techniques are being utilised more frequently in the management of acute and chronic pulmonary emboli; however, robust clinical evidence is only emerging for the utilisation of these techniques. Hence, there is a need for a robust mechanism of patient selection and careful consideration of the benefits and risks of the interventions. In this review, we discuss the risk stratification mechanisms; the role of the multidisciplinary pulmonary embolism response team to support decision-making; and describe the various commonly used interventional techniques and how these can be integrated into treatment strategies for the benefit of our patients.

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.

Contemporary Management of Acute Pulmonary Embolism: Evolution of Catheter-based Therapy

Acute pulmonary embolism (PE) affects more than 100 000 people in the United States annually and is the third leading cardiovascular cause of death. The standard management for PE is systemic anticoagulation therapy. However, a subset of patients experience hemodynamic decompensation, despite conservative measures. Traditionally, these patients have been treated with systemic administration of thrombolytic agents or open cardiac surgery, although attempts at endovascular treatment have a long history that dates back to the 1960s. The technology for catheter-based therapy for acute PE is rapidly evolving, with multiple devices approved over the past decade. Currently available devices fall into two broad categories of treatment methods: catheter-directed thrombolysis and percutaneous suction thrombectomy. Catheter-directed thrombolysis is the infusion of thrombolytic agents directly into the occluded pulmonary arteries to increase local delivery and decrease the total dose. Suction thrombectomy involves the use of small- or large-bore catheters to mechanically aspirate a clot from the pulmonary arteries without the need for a thrombolytic agent. A thorough understanding of the various risk stratification schemes and the available evidence for each device is critical for optimal treatment of this complex entity. Multiple ongoing studies will improve our understanding of the role of catheter-based therapy for acute PE in the next 5-10 years. A multidisciplinary approach through PE response teams has become the management standard at most institutions. An invited commentary by Bulman and Weinstein is available online. Online supplemental material is available for this article. ^©RSNA, 2022.

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.

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.

FlowTriever Retrieval System for the treatment of pulmonary embolism: overview of its safety and efficacy

INTRODUCTION

Pulmonary embolism (PE) is the third leading cause of cardiovascular mortality. There has been little change in PE mortality rates over the past two decades making this an appealing area for innovation and development.

AREAS COVERED

While anticoagulation (AC) and systemic thrombolysis (ST) are the mainstay treatments for high-risk PE and intermediate-high-risk PE with decompensation, advancements in catheter- based therapies offer potential alternatives. Areas covered here will include present guidelines for PE treatment and the landscape of catheter-directed therapies with a focus on the FlowTriever (FT) Retrieval System. Available safety and efficacy data will be reviewed. An online search via Google Scholar and PubMed with the keywords INARI Flowtriever, venous thromboembolism, and pulmonary embolism, alongside bibliographies of published articles, was undertaken as a review of the literature on the FlowTriever system for this device overview.

EXPERT OPINION

The five-year outlook on the role of catheter-directed therapies in the management of PE includes continued innovation in catheter-directed therapies and a number of high-quality trials on the horizon.

Catheter-directed therapy in pulmonary embolism

Acute pulmonary embolism (PE) is a life-threatening condition with high mortality rates and potential long-term sequelae. Systemic thrombolysis has been virtually the only therapeutic option available for patients with hemodynamic instability over decades. Recently, interventional therapy of PE has gained increasing interest. Multiple devices were developed; these include devices for local thrombolysis, thrombus fragmentation, thrombus aspiration, and combined approaches. However, the available evidence is limited to mostly small, nonrandomized studies. In these studies, safety and efficacy data from patients with intermediate or high-risk PE are promising. However, due to the lack of adequately powered randomized trials, interventional treatment of intermediate or high-risk PE cannot be recommended as standard-of-care. The decision on whether and how to perform a catheter-based intervention should therefore be left to the discretion of the local team, depending on the patients' clinical status, bleeding risk, local expertise, and available devices. The implementation of local multidisciplinary PE response teams is recommended by international guidelines to provide the best possible treatment.

AngioVac Aspiration Thrombectomy of Right Atrial Thrombus is Safe and Effective in Cancer Patients

OBJECTIVES

The aim of this study was to test the hypothesis that endovascular aspiration thrombectomy of right atrial thrombus (RAT) using the AngioVac device is as safe and effective in patients with cancer as those without cancer.

BACKGROUND

RAT is a uniquely challenging clinical presentation of venous thromboembolism due to its low incidence and historically high-risk of mortality due to thrombus propagation into the pulmonary arteries. There is a lack of consensus regarding management, particularly in high-risk cancer patients. Endovascular aspiration thrombectomy utilizing the AngioVac device is effective in removal of right atrial thrombus and may be a safer option for patients with cancer in whom avoidance of higher-risk intervention is preferred.

METHODS

This was an institutional review board-approved retrospective single-center case control study of patients with RAT who underwent AngioVac aspiration thrombectomy between August 2013 and July 2020. Analysis of patient demographics and clinical characteristics, thrombus-related factors, and operative details was performed. Primary endpoints included survival, safety, and technical success.

RESULTS

A total of 44 patients met inclusion criteria, 20 of whom with active malignancy. The oncology group had a significantly higher Charlson comorbidity index (P = 0.01). Comparative outcomes between the oncology and non-oncology group showed no difference in survival (P = 0.8) or technical success (OR 3, 95% CI 0.83-10.9). There were 9 complications, including 6 minor, 1 moderate, 1 severe, and 1 death.

CONCLUSIONS

AngioVac aspiration thrombectomy of RAT is as safe and effective in patients with cancer as those without cancer.

Aspiration thrombectomy for acute pulmonary embolism with an intermediate-high risk

INTRODUCTION AND PURPOSE

The treatment of acute pulmonary embolism (PE) with an intermediate-high risk of mortality at 30 days is still not well defined, recommending the latest clinical guidelines of the European Society of Cardiology 2019 exclusively anticoagulant treatment, reducing the indication for mechanical thrombectomy to high-risk patients or intermediate-high risk patients with poor hemodynamic evolution. Our purpose is to determine the safety and efficacy of aspiration thrombectomy in intermediate-high risk patients with PE and to analyze possible differences in these results between hemodynamically unstable patients (massive PE) and hemodynamically stable patients (submassive PE).

METHODS

We analyzed all patients who underwent aspiration thrombectomy for PE at our tertiary university hospital during a 34-month period. We compared echocardiographic parameters (right ventricular diameter, tricuspid plane annular plane systolic excursion (TAPSE), S' wave, and pulmonary hypertension), respiratory parameters (PaO₂/FiO₂ ratio), and clinical parameters recorded before and 24h after the procedure. We also analyzed bleeding complications and mortality.

RESULTS

In the 42 patients included (16 with massive PE and 26 with submassive PE), aspiration thrombectomy resulted in significant improvements in right ventricular diameter, TAPSE, S' wave, andPaO₂/FiO₂ ratio. Of the 8 patients administered fibrinolysis, 4 developed bleeding complications. Only one direct complication of the procedure was observed (pulmonary artery rupture). Eight patients died in the acute phase.

CONCLUSIONS

Aspiration thrombectomy for PE is safe and effective, significantly improving respiratory and hemodynamic parameters in the first 24h after the procedure with a low rate of complications compared to fibrinolysis.

Percutaneous Thrombus Removal in COVID-19-Infected Patient with Pulmonary Embolism

We present a case describing the use of the AngioVac system (AngioDynamics, Inc.) and SENTINEL™ cerebral protection system (SCPS; Boston Scientific) in a patient with COVID-19 who initially presented with a large deep-vein thrombosis of the left lower extremity, complicated by a pulmonary embolism. Although he initially improved with systemic alteplase, he later developed a second large clot diagnosed in transit in the right atrium. Within 12 hours from initial thrombolysis, this large clot wedged across an incidental patent foramen ovale (PFO), the atrial septum, and the cavotricuspid annulus. We emergently performed a percutaneous clot extraction with preemptive placement of the SCPS in anticipation of cardioembolic phenomenon. A large (> 10 cm) clot was extracted without complication, and the patient was discharged home.

The combined use of SCPS and AngioVac in this case suggests a potential role for percutaneous treatment of severe and consequential thromboembolic disease, especially in patients with a PFO, and may be considered as an alternative and less-invasive option in patients with COVID-19. While cerebral embolic protection devices are approved for and widely used in transcatheter aortic valve replacement procedures, there is a theoretical benefit for use in percutaneous thrombolectomies as well.

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.

Endovascular therapies for pulmonary embolism

Purpose

The aim of this article is to define the place of new endovascular methods for the management of pulmonary embolisms (PE), on the basis of a multidisciplinary consensus.

Method and results

Briefly, from the recent literature, for high-risk PE presenting with shock or cardiac arrest, systemic thrombolysis or embolectomy is recommended, while for lowrisk PE, anticoagulation alone is proposed. Normo-tense patients with PE but with biological or imaging signs of right heart dysfunction constitute a group known as “at intermediate risk” for which the therapeutic strategy remains controversial. In fact, some patients may require more aggressive treatment in addition to the anticoagulant treatment, because approximately 10% will decompensate hemodynamically with a high risk of mortality. Systemic thrombolysis may be an option, but with hemorrhagic risks, particularly intra cranial. Various hybrid pharmacomechanical approaches are proposed to maintain the benefits of thrombolysis while reducing its risks, but the overall clinical experience of these different techniques remains limited. Patients with high intermediate and high risk pulmonary embolism should be managed by a multidisciplinary team combining the skills of cardiologists, resuscitators, pneumologists, interventional radiologists and cardiac surgeons. Such a team can determine which intervention – thrombolysis alone or assisted, percutaneous mechanical fragmentation of the thrombus or surgical embolectomy – is best suited to a particular patient.

Conclusions

This consensus document define the place of endovascular thrombectomy based on an appropriate risk stratification of PE.

Emergent mechanical thrombectomy for right atrial clot and massive pulmonary embolism using flowtriever

This case demonstrated a feasible alternative to treat "clot in transit" associated with pulmonary embolism using FlowTriever Inari device. The pre-existing approved AngioVac device requires extracorporeal circulation support and more invasiveness. FlowTriever permits mechanical thrombectomy with versatile approach without additional extracorporeal perfusion setting. Additional studies are required to reach a definitive conclusion.

Current Endovascular Treatment Options in Acute Pulmonary Embolism

Acute pulmonary embolism (PE) is a significant cause of mortality and morbidity across the globe. Over the last few decades, there have been major therapeutic advances in acute PE management, including catheter-based therapy. However, the effectiveness of catheter-based therapy in acute PE is not supported by Level I evidence, making the use of this promising treatment rather controversial and ambiguous. In this paper, we discuss the risk stratification of acute PE and review the medical and endovascular treatment options. We also summarize and review the data supporting the use of endovascular treatment options in acute PE and describe the potential role of the PE response team.

Reperfusion therapies in pulmonary embolism-state of the art and expert opinion: A position paper from the "Unité de Soins Intensifs de Cardiologie" group of the French Society of Cardiology

Acute pulmonary embolism is a frequent cardiovascular emergency with an increasing incidence. The prognosis of patients with high-risk and intermediate-high-risk pulmonary embolism has not improved over the last decade. The current treatment strategies are mainly based on anticoagulation to prevent recurrence and reduce pulmonary vasculature obstruction. However, the slow rate of thrombus lysis under anticoagulation is unable to acutely decrease right ventricle overload and pulmonary vasculature resistance in patients with severe obstruction and right ventricle dysfunction. Therefore, patients with high-risk and intermediate-high-risk pulmonary embolism remain a therapeutic challenge. Reperfusion therapies may be discussed for these patients, and include systemic thrombolysis, catheter-directed therapies and surgical thrombectomy. High-risk patients require systemic thrombolysis, but may have contraindications as a result of the high risk of bleeding. In addition, intermediate-high-risk patients should not receive systemic thrombolysis, despite its high efficacy, because of prohibitive bleeding complications. Recently, percutaneous reperfusion techniques have been developed to acutely decrease pulmonary vascular obstruction with lower-dose or no thrombolytic agents and, thus, potentially higher safety than systemic thrombolysis. Some of these techniques improve key haemodynamic variables. Cardiac surgical techniques and venoarterial extracorporeal membrane oxygenation as temporary circulatory support may be useful in selected cases. The development of pulmonary embolism centres with multidisciplinary pulmonary embolism teams is mandatory to enable adequate use of reperfusion and improve outcomes. We aim to present the state of the art regarding reperfusion therapies in pulmonary embolism, but also to provide guidance on their indications and patient selection.

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.

Vacuum-assisted extraction of ilio-caval and right heart masses: A 5-year single center experience

PURPOSE

Despite paucity of data, there exists growing popularity of catheter-based extraction methods for intravascular thrombi and vegetations. We describe a large single center experience with vacuum-assisted extraction techniques (VAET) for right-sided intravascular and cardiac masses.

METHODS

We retrospectively reviewed the perioperative course of patients undergoing VAET between 2014 and 2019. Primary outcomes were survival and freedom from recurrent bacteremia. Procedural success was a composite definition of survival, majority of mass extraction, absence of recurrent bacteremia, and valve function not requiring further intervention during index hospitalization.

RESULTS

Of the entire cohort (n = 58), 48% and 52% underwent VAET for vegetations and sterile thrombi, respectively. Of those with positive cultures, the most common organism isolated was Staphylococcus aureus (48%). Preoperative active bacteremia was present in 36% (21/58) and of these patients, 76% (16/21) had neither recurrent nor persistent bacteremia post-op. The majority of masses (67%, 38/58) were debulked with an average reduction in size of 42%. Conversion to open surgery occurred in 3.5% (2/58). Intraoperative and 30-day survival were 98% (57/58) and 90% (28/31), respectively. Overall success was 86% (50/58). The prevalence of moderate/severe tricuspid regurgitation was 37% pre-op and 61% post-op. Average length of intensive care unit and overall hospital stay was 5.6 and 16 days, respectively.

CONCLUSIONS

In this single center experience, VAET was conducted safely with a high degree of success and freedom from short-term recurrent bacteremia. This minimally invasive procedure is an attractive alternative to traditional open techniques for removal of right-sided intravascular and cardiac masses.

Interventional Radiology Therapy: Inferior Vena Cava Filter and Catheter-based Therapies

Endovascular management of pulmonary embolism can be divided into therapeutic and prophylactic treatments. Prophylactic treatment includes inferior vena cava filter placement, whereas endovascular therapeutic interventions include an array of catheter-directed therapies. The indications for both modalities have evolved over the last decade as new evidence has become available.

Percutaneous Vacuum-Assisted Thrombectomy Using AngioVac Aspiration System

BACKGROUND

Surgical embolectomy and thrombolytic therapy are two common approaches for the treatment of large intra-cardiac or intravascular thrombi to prevent new or worsening pulmonary embolism (PE). Considering high operative mortality with surgical embolectomy and high bleeding risk with thrombolytic therapy, patients who are poor candidates for these treatments may benefit from percutaneous aspiration thrombectomy/Vacuum-assisted thrombectomy (VAT). AngioVac aspiration system was granted 510(k) clearance by the United States Food and Drug Administration (FDA) in April 2009. We present a case series to describe its use and outcomes in evacuating large caval thrombi or intracardiac masses.

METHODS

We did a retrospective analysis of AngioVac catheter based thrombectomy in 16 consecutive patients treated between January 2016 and January 2019 to report case characteristics and in-hospital clinical outcomes.

RESULTS

Sixteen patients (mean age 48) underwent 16 AngioVac procedures over 48 months. Indications included intracardiac mass (68.8%), caval thrombus (56.3%), and catheter associated thrombus (43.8%). 7 (43.8%) patients had concurrent PE. Peri-procedure mortality was 0% and in-hospital mortality was 12.5% at a mean follow-up of 14 days. There were no pulmonary hemorrhages, strokes or myocardial infarctions. 62.5% had a significant drop in hemoglobin, which required a blood transfusion but there was no episode of overt bleeding.

CONCLUSION

The AngioVac aspiration system has been shown to be effective at aspirating large volumes of intravascular and intracardiac thrombus. It is a reasonable alternative to surgical thrombectomy in patients with large central thrombi or masses in-transit who are at risk of complicated PE.

Catheter-directed therapy for acute pulmonary embolism: navigating gaps in the evidence

Systemic thrombolysis for acute pulmonary embolism (PE) reduces the risk of death and cardiovascular collapse but is associated with an increased rate of bleeding. The desire to minimize the risk of bleeding events has driven the development of catheter-based strategies for pulmonary reperfusion in PE. These catheter-based strategies utilize lower-dose fibrinolytic regimens or purely mechanical techniques to expedite removal of the embolus. Several devices providing mechanical or suction embolectomy and catheter-directed thrombolysis, with or without facilitation by ultrasound, have been tested. Data are inconsistent regarding the efficacy and safety of mechanical and suction embolectomy. The most comprehensive data on catheter-based techniques stem from trials of ultrasound-facilitated catheter fibrinolysis. Ultrasound-facilitated catheter fibrinolysis relieves right ventricular pressure overload with a lower risk of major bleeding and intracranial haemorrhage than historical rates with systemic fibrinolysis. However, further research is required to determine the optimal application of ultrasound-facilitated catheter fibrinolysis and other catheter-based therapies in patients with acute PE.

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.

Interventional Therapies for Acute Pulmonary Embolism: Current Status and Principles for the Development of Novel Evidence: A Scientific Statement From the American Heart Association

Pulmonary embolism (PE) represents the third leading cause of cardiovascular mortality. The technological landscape for management of acute intermediate- and high-risk PE is rapidly evolving. Two interventional devices using pharmacomechanical means to recanalize the pulmonary arteries have recently been cleared by the US Food and Drug Administration for marketing, and several others are in various stages of development. The purpose of this document is to clarify the current state of endovascular interventional therapy for acute PE and to provide considerations for evidence development for new devices that will define which patients with PE would derive the greatest net benefit from their use in various clinical settings. First, definitions and limitations of commonly used risk stratification tools for PE are reviewed. An adjudication of risks and benefits of available interventional therapies for PE follows. Next, considerations for optimal future evidence development in this field are presented in the context of the current US regulatory framework. Finally, the document concludes with a discussion of the pros and cons of the rapidly expanding PE response team model of care delivery.

Safety and Efficacy of Acute Pulmonary Embolism Treated via Large-Bore Aspiration Mechanical Thrombectomy Using the Inari FlowTriever Device

PURPOSE

To report initial experience with safety and efficacy in the treatment of pulmonary embolism (PE) using the FlowTriever device.

MATERIALS AND METHODS

A single-center retrospective study was performed in all patients with acute central PE treated using the FlowTriever device between March 2018 and March 2019. A total of 46 patients were identified (massive = 8; submassive = 38), all with right ventricular (RV) strain and 26% with thrombolytic contraindications. Technical success (according to SIR reporting guidelines) and clinical success (defined as mean pulmonary artery pressure intraprocedural improvement) are reported, as are major device and procedure-related complications within 30 days after discharge.

RESULTS

Technical success was achieved in 100% of cases (n = 46). Average mean pulmonary artery pressure improved significantly from before to after the procedure for the total population (33.9 ± 8.9 mm Hg before, 27.0 ± 9.0 mm Hg after; P < .0001; 95% confidence interval [CI], 5.0-8.8), submassive cohort (34.7 ± 9.1 mm Hg before, 27.4 ± 9.2 mm Hg after; P < .0001; 95% CI, 5.2-9.5) and massive cohort (30.4 ± 6.9 mm Hg before, 25.4 ± 8.2 mm Hg after; P < .05; 95% CI:0.4-9.6). Intraprocedural reduction in mean pulmonary artery pressure was achieved in 88% (n = 37 of 42). A total of 100% of patients (n = 46 of 46) survived to hospital discharge. In total, 71% of patients (n = 27 of 38) experienced intraprocedural reduction in supplemental oxygen requirements. Two major adverse events (4.6%) included hemoptysis requiring intubation, and procedure-related blood loss requiring transfusion. No delayed procedure-related complications or deaths occurred within 30 days of hospital discharge.

CONCLUSIONS

Initial clinical experience using the FlowTriever to perform mechanical thrombectomy showed encouraging trends with respect to safety and efficacy for the treatment of acute central, massive, and submassive pulmonary embolism.

Catheter-based therapies in acute pulmonary embolism

AIMS

To provide a systematic review of catheter-based therapies of acute pulmonary embolism.

METHODS AND RESULTS

Studies published in peer-reviewed journals before February 2017 were included and categorized according to the mechanism of thrombus removal: fragmentation, rheolytic therapy, aspiration or catheter-directed thrombolysis. Strengths, challenges and the level of evidence of each device were evaluated. We found 16 different catheter-based therapies for acute PE; all but one being used off-label. The majority of procedures involve catheter-directed thrombolysis. Aspiration therapy shows promise, but limited data are available. Rheolytic therapy should be used with caution, if at all, due to the high number of associated complications.

CONCLUSIONS

Catheter-based therapies show promise as a treatment for acute PE, though evidence is lacking. Further research into the efficacy and safety of devices is needed.

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.

Managing large lead vegetations in transvenous lead extractions using a percutaneous aspiration technique

BACKGROUND

Treatment of patients with systemic infections of cardiac implantable electronic devices and large lead vegetations are a clinical challenge. In such situations patients potentially had to undergo open surgical extraction in the past. The objective of this study was to evaluate the results of a concomitant percutaneous, minimal-invasive aspiration procedure with the use of an extracorporeal circulation in transvenous lead extraction procedures in patients with large lead vegetations.

RESEARCH DESIGN AND METHODS

Prior and during transvenous lead extraction procedures lead vegetations were targeted for removal with a percutaneous aspiration technique based on a veno-venous extracorporeal circulation with an in-line filter. Clinical outcomes of the procedures were retrospectively analyzed.

RESULTS

This innovative and minimal-invasive treatment concept was used in 35 patients with systemic CIED infections (mean echocardiographic lead vegetation size 22.6 (12-40) mm). Complete procedural success of the aspiration procedure was seen in 88.6% of the patients. No major complication related to the aspiration procedure occurred. Clinical success of the concomitant transvenous lead extraction procedures (35 patients, 83 leads) was 97.1%.

CONCLUSION

The presented data show that the aspiration procedure is safe and efficient as an adjunct in transvenous lead extraction procedures avoiding the need for open surgical extraction in such cases.

Percutaneous Pulmonary Embolism Thrombectomy and Thrombolysis: Technical Tips and Tricks

Catheter-directed therapy (CDT) is now acknowledged as a treatment option for select patients with acute massive or submassive pulmonary embolism (PE), and more patients are being considered for CDT if there is available expertise. Therefore, interventionalists should be aware of the variety of catheter-based treatment options, specific pitfalls to avoid during therapy, and the appropriate treatment endpoints. This article reviews currently available techniques and protocols for treating acute massive and submassive PE, with tips to safely and successfully perform percutaneous PE interventions.

Intervention in Massive Pulmonary Embolus: Catheter Thrombectomy/Thromboaspiration versus Systemic Lysis versus Surgical Thrombectomy

Massive pulmonary embolus (PE), defined as hemodynamic shock from acute PE, is a life-threatening condition. Deaths from massive PE, especially when unsuspected, occur within minutes to hours of onset and as such prompt intervention can be lifesaving. Acute massive PE patients have traditionally been candidates for treatment with intravenous systemic thrombolysis to improve pulmonary artery pressure, arteriovenous oxygenation, and pulmonary perfusion in an effort to reduce mortality. However, patients with contraindications to systemic thrombolysis or those who have failed thrombolysis may benefit from other techniques including endovascular and surgical embolectomy. This article will review the current medical management as well as catheter-directed therapies and surgical embolectomy in the treatment of patients with massive PE.

Endovascular treatment of pulmonary embolism: Selective review of available techniques

Acute pulmonary embolism (PE) is the third most common cause of death in hospitalized patients. The development of sophisticated diagnostic and therapeutic modalities for PE, including endovascular therapy, affords a certain level of complexity to the treatment of patients with this important clinical entity. Furthermore, the lack of level I evidence for the safety and effectiveness of catheter directed therapy brings controversy to a promising treatment approach. In this review paper, we discuss the pathophysiology and clinical presentation of PE, review the medical and surgical treatment of the condition, and describe in detail the tools that are available for the endovascular therapy of PE, including mechanical thrombectomy, suction thrombectomy, and fibrinolytic therapy. We also review the literature available to date on these methods, and describe the function of the Pulmonary Embolism Response Team.

Ekosonic Endovascular System (EKOS) in a trauma patient with intracranial bleed, recent major surgery, and massive pulmonary embolus: A case report

Pulmonary embolism is a life-threatening condition treated with anticoagulation and systemic thrombolysis when appropriate. In patients with contraindications to thrombolysis, catheter-directed thrombolysis may be considered. Here, we present a patient with massive pulmonary embolus and 3 contraindications to systemic thrombolysis who was successfully treated with pharmacomechanical thrombolysis using the Ekosonic Endovascular System.