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

Thrombus vs Tumor: Use of AngioVac in a RV Mass

This paper present a challenging case of a right ventricular mass in a patient who was at high surgical risk for open removal. The minimally invasive AngioVac device has been used with a successful 50% reduction in mass burden. This report illustrates AngioVac as a safe alternative to invasive surgery.

AngioVac Procedures: Integration of cardiac surgeon and anesthesiologist-led transesophageal echocardiography: A preliminary report

Introduction

The AngioVac system is a novel, minimally invasive, endovascular technique used to evacuate intravascular or intracardiac vegetation or thrombus. Although most AngioVac procedures are currently performed by interventionalists, this innovative procedure has been gaining attention among the surgical and anesthesia communities.

Methods

We retrospectively reviewed all patients who underwent the AngioVac procedure performed by a cardiac surgeon between August 2019 and December 2022. Fellowship-trained cardiac anesthesiologists operated TEE to navigate the AngioVac cannula during the procedure. The stored TEE images were retrospectively reviewed and independently analyzed by two cardiac anesthesiologists with specific focus on TEE-guided navigation of the AngioVac cannula towards the aspiration target.

Results

Eleven patients underwent the AngioVac procedure during the study period. In nine cases, the majority of the vegetation or thrombus was successfully aspirated. In two cases, incomplete aspiration was attributed to the mass burden being too large, firm, and chronic in etiology. Worsening tricuspid regurgitation (TR) was identified in three of the 11 cases. Intraoperative TEE provided the cardiac surgeon with simultaneous display of the AngioVac cannula shaft, its tip, and aspiration target, as well as real-time assessment of TR, facilitating the minute movements essential for successful outcomes.

Conclusions

This study details our experience and the effectiveness of the AngioVac system for treating soft, intracardiac vegetation or thrombus in a minimally invasive manner. Experienced cardiac anesthesiologists have the skillsets and knowledge to provide optimal live TEE imaging necessary for successful maneuvering of the AngioVac cannula.

Evidence-Based Update on Transcatheter Therapies for Pulmonary Embolism

PURPOSE OF REVIEW

Pulmonary embolism (PE) remains a leading cause of cardiovascular morbidity and mortality. Multiple new therapies are in development and under study to improve our contemporary care of patients with PE. We review and compare here these novel therapeutics and technologies.

RECENT FINDINGS

Multiple novel therapeutic devices have been developed and are under active study. This work has advanced the care of patients with intermediate and high-risk PE. Novel therapies are improving care of complex PE patients. These have inspired large multicenter international randomized controlled trials that are actively recruiting patients to advance the care of PE. These studies will work towards advancing guidelines for clinical care of patients with PE.

Modern Treatment of Pulmonary Embolism (USCDT vs MT): Results From a Real-World, Big Data Analysis (REAL-PE)

Background

Advanced therapies are increasingly utilized to treat pulmonary embolism (PE). A unique data platform allows access to electronic health record data for comparison of the safety of PE therapies.

Methods

All data from Truveta (Truveta, Inc) were analyzed (16 systems, 83,612,413 patients, 535,567 with PE). All patients treated with ultrasound-assisted catheter-directed thrombolysis (USCDT) (Boston Scientific) or mechanical thrombectomy (MT) (Inari Medical) for PE were identified. The primary analysis was based on index procedures performed from January 2009 to May 2023, and contemporary analysis on those performed from January 2018 to May 2023. Bleeding was assessed via direct laboratory analysis and transfusion administration documentation. International Society for Thrombosis and Hemostasis (ISTH) and Bleeding Academic Research Consortium (BARC) 3b definitions were recreated. Multiple logistic regression analysis of major bleeding was performed. In-hospital death and median length of stay were measured.

Results

For the primary analysis, 2259 patients (N = 1577 USCDT, N = 682 MT) and for the contemporary analysis 1798 patients (N = 1137 USCDT, N = 661 MT) met the criteria. Incidence of hemoglobin reduction (>2 and >5 g/dL) and transfusions received were significantly higher among MT-treated patients in both analyses, as was ISTH and BARC 3b major bleeding (primary: ISTH MT 17.3% vs USCDT 12.4% P = .002; BARC 3b MT 15.4% vs USCDT 11.8% P = .019) (contemporary: ISTH MT 17.2% vs USCDT 11.0% P = .0002; BARC 3b MT 15.4% vs USCDT 10.6% P = .002). Regression analysis demonstrated that MT is associated with major bleeding. Median length of stay, all-cause 30-day readmission and in-hospital mortality were similar between groups. Intracranial hemorrhage was more common with MT.

Conclusions

Major bleeding derived from direct laboratory and transfusion data occurred more frequently with MT vs USCDT. Intracranial hemorrhage was more common among MT-treated patients. In the absence of randomized data, these results provide guidance regarding the bleeding risk and safety of strategies for advanced PE therapy.

Scoping review of percutaneous mechanical aspiration for valvular and cardiac implantable electronic device infective endocarditis

BACKGROUND

Percutaneous mechanical aspiration (PMA) of intravascular vegetations is a novel strategy for management of patients with infective endocarditis (IE) who are at high risk of poor outcomes with conventional cardiac surgery. However, clear indications for its use as well as patient outcomes are largely unknown.

OBJECTIVES

To conduct a scoping review of the literature to summarize patient characteristics and outcomes of those undergoing PMA for management of IE.

METHODS

Two independent reviewers screened abstracts and full text for inclusion and independently extracted data.

DATA SOURCES

MEDLINE, Embase, and Web of Science.

STUDY ELIGIBILITY CRITERIA

Studies published until February 21, 2023, describing the use of PMA for management of patients with cardiac implantable electronic device (CIED) or valvular IE were included.

ASSESSMENT OF RISK OF BIAS

As this was a scoping review, risk of bias assessment was not performed.

METHODS OF DATA SYNTHESIS

Descriptive data was reported.

RESULTS

We identified 2252 titles, of which 1442 abstracts were screened, and 125 full text articles were reviewed for inclusion. Fifty-one studies, describing a total of 294 patients who underwent PMA for IE were included in our review. Over 50% (152/294) of patients underwent PMA to debulk cardiac implantable electronic device lead vegetations prior to extraction (152/294), and 38.8% (114/294) of patients had a history of drug use. Patient outcomes were inconsistently reported, but few had procedural complications, and all-cause in-hospital mortality was 6.5% (19/294).

CONCLUSIONS

While PMA is a promising advance in the care of patients with IE, higher quality data regarding patient outcomes are needed to better inform the use of this procedure.

Percutaneous Intracardiac Mass Extraction in High Surgical-Risk Patients

Large intracardiac masses including tumors, thrombi, and vegetations result in detrimental embolic or obstructive sequelae and present a management dilemma. Open heart surgery, the traditional approach, may not be an option for many patients with a prohibitive surgical risk due to multiple comorbidities. Recently, percutaneous options have emerged with reported success in extracting such intracardiac masses. A 42-year-old female with history of advanced primary sclerosing cholangitis with decompensated liver cirrhosis causing ascites and variceal bleed presented to the emergency department with fatigue, subjective fevers, chills and melena. Laboratory results revealed neutrophil-predominant leukocytosis and normocytic anemia, and blood cultures were positive for Candida albicans. Electrocardiography showed sinus tachycardia. Chest X-ray was unremarkable. She underwent packed red blood cell transfusion and esophageal banding for variceal bleeding. Transthoracic echocardiogram revealed normal left ventricular ejection fraction and no wall motion abnormalities. A right atrial mobile mass measuring approximately 1.0 × 3.0 cm was noted. Multidisciplinary heart team discussion concluded that while the mass posed a high embolic risk, the patient had a prohibitive risk for surgical intervention. Successful percutaneous removal of the mass using Penumbra system device (Penumbra Incorporated, Alameda, CA) was accomplished. This case report details the procedure and outcomes, as well as presents a literature review.

Surgical Management of Renal Cell Carcinoma with Inferior Vena Cava Tumor Thrombus

Most kidney cancers are primary renal cell carcinomas (RCC) of clear cell histology. RCC is unique in its ability to invade into contiguous veins - a phenomenon terms venous tumor thrombus. Surgical resection is indicated for most patients with RCC and an inferior vena cava (IVC) thrombus in the absence of metastatic disease. Resection also has an important role in selected patients with metastatic disease. In this review, we discuss the comprehensive management of the patient with RCC with IVC tumor thrombus, emphasizing a multidisciplinary approach to the surgical techniques and perioperative management.

AngioVac for Vegetation Debulking in Right-sided Infective Endocarditis: A Systematic Review and Meta-Analysis

OBJECTIVES

To investigate the utility of AngioVac-assisted vegetation debulking (AVD) in right sided infective endocarditis (RSIE) BACKGROUND: : AngioVac is a vacuum-based device that was approved in 2014 for the percutaneous removal of undesirable materials from the intravascular system. Although there are multiple reports on the use of the AngioVac device to aspirate right-sided heart chamber thrombi, data on its use to treat RSIE is limited.

METHODS

We performed a comprehensive literature search for studies that evaluated the utility of AVD. The primary outcomes of our study were the procedural success, defined as the ability of AngioVac to produce residual vegetation size <50% (RVS<50%) without serious procedural complications, and the clinical success, defined as composite of RVS<50%, in-hospital survival, absence of recurrent bacteremia, and valve function not requiring further intervention. The secondary outcomes included the individual components of the primary outcomes and average length of hospital stay. The pooled means and proportions of our data were analyzed using random effects model, generic inverse variance method, and represented with 95% confidence intervals (CIs).

RESULTS

A total of 44 studies, including 301 patients (mean age: 44.6±18.2 years, 71.6% males) were included. Procedural success was achieved in 89.2% of patients (95% CI:82.3%-93.6%, I²=0%). Clinical success was achieved in 79.1% of patients (95%CI:67.9%-87.2%, I²=15%). Overall survival rate was 89.7% (95% CI:83.1%-93.9%%, I²=9%).

CONCLUSIONS

Our meta-analysis demonstrates that AVD is a promising therapeutic option for RSIE offering a high success rate with an acceptable complication rate across a wide range of patients.

A Rare Case of a Failed AngioVac Procedure Used to Debride Tricuspid Vegetation Complicated by Ogilvie Syndrome

Ogilvie syndrome is a rare disorder characterized by dilatation of part or all of the colon and rectum without intrinsic or extrinsic mechanical obstruction. Its etiology is likely multifactorial with high mortality if left untreated. Here, we report for the first time a case of Ogilvie syndrome secondary to the AngioVac procedure. Because our patient had a high operative risk, we used the AngioVac system to debulk tricuspid valve vegetations to reduce bacterial load. Although AngioVac is considered safe overall, publications describing its side effects, safety, and efficacy are limited. Providers should be aware of this rare but potentially fatal complication and the importance of close clinical monitoring and serial abdominal examinations following AngioVac procedures.