Novel Use of AngioVac System to Prevent Pulmonary Embolism during Radical Nephrectomy with Inferior Vena Cava Thrombectomy

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.

Novel use of the AngioVac system

The Vortex Medical AngioVac Cannula was employed in a 71-year-old man with a renal neoplasm with occlusion of the inferior vena cava and involvement of the right atrial cavity. Due to the presence of diffuse metastases, surgery was not indicated, and the AngioVac system was employed to remove the free-floating mobile atrial mass, thus minimizing the risk of pulmonary embolism and as a bioptic tool to allow a correct histological diagnosis. This novel use of this system may be advantageous in other similar cases.

Non-surgical extraction of right atrial mass by AngioVac aspiration device under fluoroscopic and transesophageal echocardiographic guidance

Right-sided cardiac masses are commonly encountered. We present a challenging case of a right atrial thrombus in a patient who had a high surgical risk for open removal. AngioVac aspiration device, under transesophageal echocardiography (TEE) and fluoroscopy guidance, was successfully used to remove the thrombus. The patient tolerated the procedure well and was discharged home. Our case confirms the safety and efficacy of this procedure for treatment of unwanted intracardiac and intravascular masses in patients who are not candidates for conventional therapies of surgery or thrombolytics.

Early Experience with AngioVac Aspiration in the Pulmonary Arteries

Five consecutive cases in which the AngioVac aspiration cannula was used for the management of pulmonary embolism (PE) were retrospectively reviewed. Four cases (80%) presented with massive PE, and two (40%) were technically successful (reduction in Miller index ≥ 5). Four patients (80%) died at a mean of 7.3 days after the procedure, including one death related to right ventricular free wall perforation. Although the AngioVac aspiration cannula has shown clinical promise in a variety of clinical applications, early experience in the pulmonary arteries has shown limited success, and further study and careful patient selection are required.

Percutaneous Embolectomy of Serpentine Thrombus from the Right Atrium in a 51-Year-Old Man

Treatment of large, fresh thrombi in the vascular system can be challenging. AngioVac, a cardiopulmonary pump system, has been used to remove large thrombi and even some tumors by a percutaneous route. We report here a case of a 51-year-old man who presented with a large thrombus (7.5 × 1.5 cm) in his inferior vena cava, extending into his right atrium and right ventricle. Because the surgical risk was high, we attempted percutaneous embolectomy via the AngioVac aspiration system. We also review the literature concerning this emerging technique.

The Angiovac Device: Understanding the Failures on the Road to Success

Objective

Current percutaneous thromboembolectomy techniques may obviate surgical intervention in high-risk patients with iliocaval thrombus or thrombus of the right side of the heart, but typically require thrombus fragmentation and thrombolysis with associated bleeding and thromboembolic complications. The AngioVac (Angiodynamics, Latham, NY USA) device uses a percutaneous venovenous bypass circuit to aspirate intact thrombus. A review of the literature was performed with regard to the AngioVac device to determine the factors correlating with successful thrombus extraction.

Methods

A literature search was performed with regard to use of the AngioVac device using the PubMed database. A meta-analysis was not performed given the small size and lack of statistical analysis of the individual reports included.

Results

Twenty-three reports describing 57 procedures in 56 patients were analyzed. Indications for thrombectomy included iliocaval thrombus in 53% (30), thrombus of the right side of the heart, in 49% (28), pulmonary embolus in 14% (8), and upper extremity venous/Glenn shunt thrombosis in 7% (4). The complete success rate, defined as removal of all thrombus, was 75% (43), with an 11% (6) partial success rate. In 14% (8) of cases, minimal or no thrombus was retrieved. When analyzed by indication, iliocaval thrombus and thrombus of the right side of the heart demonstrated 87% (26) and 82% (23) complete success rates, respectively. Pulmonary embolus demonstrated a significantly lower success rate at 12.5% [1; (P < .001)]. Complications occurred in 12% (7), including six hematomas and one retroperitoneal bleed.

Conclusions

The AngioVac device offers an excellent alternative to surgical thrombectomy for patients presenting with iliocaval or intracardiac thrombus, with success rates of more than 80%, although it seems that pulmonary emboli are less amenable. Appropriate patient selection can lead to improved outcomes. Larger numbers are needed to make more definite conclusions.

Endometrial Stromal Sarcoma Metastatic from the Uterus to the Inferior Vena Cava and Right Atrium

Endometrial stromal sarcoma metastases usually occur within the pelvis and rarely involve the great vessels or the heart. We present the case of a 55-year-old woman who was referred for endovascular therapy to treat presumed thrombosis of the inferior vena cava. The suspected thrombus was recalcitrant to endovascular removal with use of an AngioVac venous drainage device. Results of an intraprocedural transvenous biopsy revealed the mass to be the intravascular extension of an endometrial stromal sarcoma. The patient underwent surgical excision of the tumor, and, shortly thereafter, a hysterectomy and salpingo-oophorectomy. This complex case highlights both the rarity of malignancy masquerading as caval thrombus and the importance of multispecialty collaboration.

New method for treatment of inferior vena cava tumor thrombus – case study

Conventional surgical therapy for advanced renal venous tumor thrombi results in high morbidity, so there is a need for less invasive techniques. This report presents the first case of a successful inferior vena cava (IVC) tumor thrombus removal without complications with balloon catheter (BC) via internal jugular vein (IJV), called the venous tumor thrombus pushing with balloon catheter (VTTP BC). Under the control of transesophageal echocardiogram and fluoroscope, a balloon catheter was sleeved on the guide wire, which was already inserted into the right internal jugular vein (IJV) and was driven distally above the IVC tumor thrombus. The balloon was inflated to occlude the IVC for prevention of pulmonary embolization. After the occlusion, the guide wire was driven to the cavotomy and was opened at the ostium of the right renal vein. It was pulled at both ends and stretched to serve as a rail. The balloon was gently pushed toward the cavotomy and the thrombectomy was completed. This is a less invasive method for treatment of venous tumor thrombus level 3 that can reduce surgical time, blood loss, and complication rates compared to the existing surgical methods. Also, it can be performed without thoracotomy, cardiopulmonary bypass, hypothermic circulatory arrest, and liver mobilization.