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Endovascular Treatment of Right Heart Masses Utilizing the AngioVac System: A 6-Year Single-Center Observational Study

Endovascular Treatment of Right Heart Masses Utilizing the AngioVac System: A 6-Year... Hindawi Journal of Interventional Cardiology Volume 2021, Article ID 9923440, 7 pages https://doi.org/10.1155/2021/9923440 Research Article Endovascular Treatment of Right Heart Masses Utilizing the AngioVac System: A 6-Year Single-Center Observational Study Aashish Katapadi , Lauren Richards , William Fischer , Suhail Q. Allaqaband , Tanvir Bajwa, and M. Fuad Jan Aurora Cardiovascular and oracic Services, Aurora Sinai/Aurora St. Luke’s Medical Centers, Advocate Aurora Health, 2801 W. Kinnickinnic River Parkway, Ste. 880, Milwaukee, Wisconsin 53215, USA Correspondence should be addressed to M. Fuad Jan; publishing18@aurora.org Received 12 March 2021; Revised 27 September 2021; Accepted 12 October 2021; Published 31 October 2021 Academic Editor: Michael C. Kim Copyright © 2021 Aashish Katapadi et al. (is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Objective. To describe our institution’s experience with the AngioVac system.Background. Intracardiac and intravascular masses previously required surgical excision, but now, there are a number of minimally invasive options. With the advent of vacuum aspiration, more specifically the AngioVac System (AngioDynamics, NY, USA), there exists a system with both low mortality and minor complications. However, the number of retrospective studies remains limited. Outcome data for high-risk patients are also limited.Methods. Data were collected and analyzed in patients who underwent AngioVac therapy at our tertiary care center from January 2014 to December 2020.Results. Our results demonstrated a 93.3% intraoperative success rate and a 100% intraoperative survival rate. However, a number of complications, including but not limited to hematomas, anemia, and hypotension, occurred, as described below. Conclusions. Our experiences demonstrated good outcomes and continue to support the usefulness of the AngioVac System. (e data also support the use of AngioVac as a treatment option for the debulking or removal of right heart masses in critically ill patients. vegetations in the right atrium and ventricle, superior and 1. Introduction inferior vena cavae, and iliofemoral veins [3, 4]. (e system Intracardiac masses, specifically right-sided cardiac thrombi, has existed for a number of years, and its utility has been vegetations, and tumors, can be rare and life-threatening evaluated in a number of case studies [5–7]. However, data conditions and, moreover, are often difficult to manage. from recent clinical studies have remained limited or non- Mortality rates are often high in untreated patients [1, 2]. existent. Additionally, the AngioVac System has been con- Treatment options for these patients traditionally include sideredforoff-labeluseforavarietyofconditionsincludingas catheter-directed or systemic thrombolysis, embolectomy, an alternative to surgical thrombectomy in high-risk patients and medical management alone. Catheter-based suction for the removal or debulking of infectious vegetations and embolectomy has been successfully used for minimally in- benign or malignant tumors in the right atrium, ventricle, or vasive treatment of intravascular material. One such option is tricuspid valve. (ereare limiteddata regardingoutcomes for the AngioVac System (AngioVac Cannula and Circuit, these patients. Consequently, the purpose of this report is to AngioDynamics, NY, USA), a vacuum-assisted suction em- describe our institution’s experiences and outcomes with the bolectomy device designed to remove fresh thrombi and AngioVac System over the past 6 years. 2 Journal of Interventional Cardiology 2. Materials and Methods (e local institutional review board approved this study and AngioVac waived the requirement for informed consent. Cannula Saline 2.1. Study Population. All cases of AngioVac-assisted, catheter-based extraction techniques performed in the cardiac catheterization laboratory at our large tertiary care center from 2014 to 2020 were reviewed. (e deci- sion to proceed with AngioVac resulted from collabo- ration between multiple specialties (interventional cardiology, infectious diseases, and intensive care phy- sicians) and the patient; stability of the patient was also a consideration. Waste Bag Reinfusion Filter Cannula 2.2.AngioVacSystem. (e AngioVac System is a disposable intravenous system that is used with extracorporeal circu- latory support. It can be used to remove fresh, soft thrombi, emboli, or vegetations in the right atrium and ventricle, superior and inferior vena cavae, and iliofemoral veins. (e system consists of a 22-F AngioVac Cannula with a self- expanding tip that is used in conjunction with a reinfusion cannula as part of a bypass circuit (Figure 1). A centrifugal Centrifugal pump enables suction at the tip, which, when deployed Pump through either the internal jugular or femoral veins, enables removal of undesirable intravascular material. Figure1:AnoverviewoftheAngioVacreperfusionsystem.(etip (e system requires two venous access sites—1 for as- is inserted either via percutaneous or surgical cutdown at the piration and 1 for reperfusion—usually utilizing a combi- internal jugular or femoral vein and connected to a suction-gen- nationoffemoralorjugularveins.(eextracorporealbypass erating bypass circuit. Blood is filtered and reinserted at the circuit consists of an outflow line, a centrifugal pump, a reinfusion cannula. filter, and an inflow line. After venous access is obtained, the centrifugal pump is activated, creating a one-way flow that provides suction at the cannula tip. (e system has a bal- 3. Results loon-activated tip to augment venous flow and facilitate removal of the thrombogenic material into the filter. (e 3.1. Preoperative Characteristics. Demographic and preop- erative variablesarelistedinTables1and2,respectively.(e circuit reinfuses filtered blood back into the body through the reperfusion cannula to minimize blood loss (Figure 1). procedure was performed on a total of 17 patients, 10 fe- males and 7 males, with an average age of 47.1 years. In- dications for AngioVac were thrombus (35.3%, n �6/17), 2.3. Data Collection. Retrospective data from each patient, septic thrombus (5.9%, n �1/17), and endocarditis (58.8%, including demographics, medical history, treatment, pro- n �10/17). All patients were critically ill with high surgical cedural indication, procedural variables, imaging data risk.(eaveragesizeofthrombusorvegetationwas3.48cm, (transthoracic/transesophageal echocardiogram, computed all located on the tricuspid valve (47.1%, n �8/17) and right tomography, and magnetic resonance imaging), and both atrium with or without vena cava involvement (41.2%,n �7/ postoperative and long-term outcomes, were recorded. 17). A number of masses were mobile (64.7%, n �11/17). Importantly, intraoperative success was defined as complete Patients with endocarditis grew methicillin-susceptible removal of the mass or removal of >50% of the clot as seen Staphylococcus aureus (MSSA; 29.4%, n �5/17), methicillin- on intraprocedural transesophageal echocardiography and resistant Staphylococcus aureus (MRSA; 17.6%, n �3/17), per procedure note. Postprocedural echocardiography was Staphylococcus epidermidis (5.9%, n �1/17), and Entero- reviewed when available. coccus faecalis (5.9%, n �1/17). Pathologic examination of the extracted mass was not performed to confirm diagnosis (Tables 1 and 2). 2.4. Statistical Analysis. Results were reported for both quantitative and categorical variables. Results for quanti- tative variables were reported as median with interquartile 3.2. Postoperative Characteristics. Postoperative variables range, and those for categorical variables were reported as are listed in Table 3. (e procedure was successful in almost frequencies and percentages. all of the patients (94.1%, n �16/17), failing only once, in a Journal of Interventional Cardiology 3 Table 1: Demographics. Characteristics n (%) or median (IQR) Sex Male 7 (41.2) Female 10 (58.8) Average age (years) 47.1 (33–64) BMI 28.1 (21.1–32.9) History End-stage renal disease 1 (5.9) Coronary artery disease 4 (23.5) Valvular disease 2 (11.8) Prior thrombotic disease 1 (5.9) CHF 3 (17.6) Diabetes 2 (11.8) Hypertension 6 (35.3) Malignancy 4 (23.5) Iatrogenic immunosuppression 2 (11.8) Prior cardiac devices 2 (11.8) BMI: body mass index; CHF: congestive heart failure; IQR: interquartile range. Table 2: Preoperative variables. Indication n (%) or median (IQR) (rombus 6 (35.3) Septic thrombus 1 (5.9) Endocarditis 10 (58.8) Bacterial cultures Methicillin-sensitive Staph. aureus 5 (29.4) Methicillin-resistance Staph. aureus 3 (17.6) Staph. epidermidis 1 (5.9) E. faecalis 1 (5.9) Polymicrobial∗ 2 Location∗∗ SVC 1 (5.9) IVC/RA 2 (11.8) RA 5 (29.4) TV 8 (47.1) Average size 3.48 (2.25–4.7) Mobility Mobile 11 (64.7) Immobile 2 (11.8) LVEF 51.9 (42–60) Hemoglobin 9.1 (7.8–10.7) Creatinine 1.12 (0.67–0.98) ∗ ∗∗ Cultures include MRSA/Strep. gordonii and Enterobacter/Klebsiella/Citrobacter/Bacteroides. Multiple locations documented. IQR: interquartile range; IVC: inferior vena cava; LVEF: left ventricular ejection fraction; MRSA: methicillin-resistant Staphylococcusaureus; RA: right atrium;Staph:Staphylococcus; Strep: Streptococci; SVC: superior vena cava; TV: tricuspid valve. patient with infective endocarditis. Almost all patients cancer, was the cause of death in 2/17 who did make it to 1 (82.4%,n �14/17) survived to discharge and to 30 days after year (11.8%). Hematoma developed in 3/17 (17.6%) after hospitalization (76.5%, n �13/17). (e 3 patients who did AngioVac use. After the procedure, a number of patients not survive to discharge expired due to septic shock, severe developed hypotension (35.3%, n �6/17), with some re- metabolic derangements, and ruptured peptic ulcer leading quiring vasopressor support (11.8%, n �2/17) and some to respiratory failure. Of the 14 discharged, 4 had expired at requiringtransfusion(29.4%,n �5/17).Othercomplications 1 year, and 6 had not met the time requirements; the 1-year included worsening tricuspid regurgitation (5.9%, n �1/17), survival decreased greatly (23.5%, n �4/17). (e leading pulmonary embolism (5.9%, n �1/17), and formation of mycotic aneurysm (5.9%, n �1/17). (e average post- cause of in-hospital death was shock, both septic (11.8%, n �2/17) and cardiogenic (5.9%, n �1/17); malignancy, procedural hospital length of stay was 8.07 days, and many more specifically advanced stage glioblastoma and colon returned homefollowing their procedure (64.7%,n �11/17). 4 Journal of Interventional Cardiology Table 3: Postoperative variables. survival to discharge and 30-day survival were 82.4% and 76.5%,respectively.Immediatesuccessforthesepatientswas Variable n (%) or median (IQR) high andprovidedanopportunity toprolonglifeincritically Operative success 16 (94.1) ill patients without increasing mortality. Out of all the pa- Survival 17 (100.0) tients, 1-year survival greatly decreased to 23.5%. However, Survival to discharge 14 (82.4) itis importanttonotethat6patients hadnotyetmadeitto1 30-day survival 13 (76.5) year and another 3 did not survive hospitalization. Of the 4 One-year survival 4 (23.5) Average LOS 8.07 (3.0–10.0) who passed away, 1 was due to progressive failure to thrive Need for tPA 0 (0.0) postprocedure, 1 was due to severe septic shock with bac- Need for transfusion 5 (29.4) teremia, and 2 were due to advanced cancers, as discussed Need for hemodialysis 0 (0.0) previously. One procedure utilizing AngioVac was unsuc- LVEF∗ 57.5 (54.25–62.75) cessful and later required surgery for an infected thrombus Side effects∗∗ on an intracardiac lead. Only 2 patients did not survive to Hematomas 3 (17.6) discharge. Of these 2, 1 passed away due to cardiogenic Shock 1 (5.9) shock in the setting of severe tricuspid regurgitation and the Hypotension 6 (35.3) other due to severe septic shock. (ough both patients had Vasopressor use 2 (11.8) moderate-sized masses and met intraoperative success, they Hemoglobin 8.7 (7.4–9.5) remained critically ill following the procedures. (e patients Creatinine 1.09 (0.63–1.15) ∗ ∗∗ who did survive past 1 year appeared to do well with no Nine patients missing postoperative LVEF. Other side effects were worseningtachycardia,PE,mycoticaneurysm,intraoperativeSVT,needfor sequelae of endocarditis. Unfortunately, many patients with intubation (2), and need for the IVC filter. IQR: interquartile range; IVC: infective endocarditis did relapse or continue using intra- inferior vena cava; LOS: length of stay; LVEF: left ventricular ejection venous drugs. (is highlights both the severity of substance fraction; PE: pulmonary embolism; SVT:supraventriculartachycardia; tPA: abuse, especially intravenous drug use, and difficulties of tissue plasminogen activator. treating this patient population. Complications most noted were hematoma at the site of catheter insertion, acute anemia requiring transfusion, and 4. Discussion persistent hypotension. Other notable complications, Strategies for intravascular or intracardiac masses tradi- though only occurring in 1 patient each, were worsening tionally revolve around anticoagulation, thrombolysis, and tricuspid regurgitation, supraventricular tachycardia and surgical interventions. In patients for whom thrombolysis is sinus tachycardia, and pulmonary embolism and mycotic contraindicated, surgical therapy such as embolectomy is an aneurysms. option. (e introduction of catheter-based rheolytic and (ere continues to exist a small number of retrospective aspiration technologies such as AngioVac offers an alter- studies involving the AngioVac System. More recently, a large registry with 234 concomitant procedures demon- native, minimally invasive approach to thrombectomy with low morbidity. AngioVac, in particular, has the advantage of strated the safety of the AngioVac System, with only 3 procedure-related deaths. (e indication for the procedure whole, intact thrombus aspiration. (is approach also de- creases the number of complications in an already high-risk was a right heart mass in 52.6% of cases; intraprocedural success, defined as >70% mass removal, was achieved in patient population. Although AngioVac is US Food and Drug Administration-approved only for thrombi and em- nearly 60% of patients with right heart masses [13]. Our own boli, this benefit makes it appealing for use with additional results coincide with previously published data, as seen in indications. Table 4, demonstrating good intraoperative success While the earliest literature referencing the AngioVac [5, 7, 14–16]. Likewise, these results also support the use of System describes the percutaneous extraction of a 1.7cm AngioVacasatreatmentoptionforcriticallyillpatientswith right atrial mass in the setting of endocarditis, the device has right-sided heart masses, as seen in Figure 2. Short-term success and survival rates are high. Information about long- been utilized on vegetations on implantable cardioverter- defibrillatorleadsandpermanentpacemakerswithasurvival term outcomes in those who undergo the AngioVac pro- cedure does not currently exist. Patients with infective benefit [4, 8]. (e variety of indications has continued to grow as cases have been added to the literature [9–11]. endocarditis have only 50% survival at 10 years, with the Patients treated for infective endocarditis with large vege- highest survival rate in people who undergo early surgery tations (>10mm) with clinical evidence of embolic phe- [17, 18]. (e AngioVac procedure provides life-prolonging nomena are often critically ill and carry a high perioperative measures otherwise unavailable for patients who may oth- risk foropen cardiacsurgery [12].AlthoughAngioVacis not erwise not live to discharge. (is supports the idea that yet approved for the debulking of infectious vegetations, it vacuum-assisted thrombectomy, specifically AngioVac at has been used for patients in inoperable situations in which this time, should be used in the algorithm for right-sided mortality is almost certain without further treatment. cardiac masses. Despite promising results at 30 days, the data are limited Our own data are characterized by use of AngioVac in a similar population and in the cardiac catheterization labo- by study size at a single center, and a larger patient pop- ulation is necessary. Additionally, there are no prospective ratory. Procedural success and procedural survival in this populationwere94.1%and100%,respectively.Furthermore, studies comparing surgery or medical management to Journal of Interventional Cardiology 5 Table 4: Prior retrospective studies. Donaldson et al. Salsamendi et al. Moriarty et al. AlBadrietal.[7] Rajput et al. [15] Fallon et al. [16] [5] [14] [13] Year 2015 2015 2016 2020 2020 2021 Patients (n) 15 7 7 16 58 234 Mean age (years) 50 49.6 51.5 48 48 50.8 Female sex (n) 3 4 5 12 27 111 Right-sided Right-sided Caval thrombus Caval thrombus IVC-associated Sterile thrombus Indication intracardiac mass intracardiac (n �11) (n �2) mass (n �3) (n �30) (n �11) mass (n �123) Catheter- Fontan conduit Pulmonary Catheter- Cardiac device- Pulmonary associated and Glenn shunt embolism associated associated embolism (n �5) thrombus mass (n �1) (n �2) thrombus (n �7) vegetation (n �8) (n �25) Catheter- Catheter- Chronic vascular Intracardiac mass associated Caval thrombus Caval thrombus associated access-associated (n �4) thrombus (n �9) (n �91) thrombus (n �2) vegetation (n �16) (n �2) Concurrent IVDU-related Pulmonary pulmonary vegetation (n �4) embolism(n �7) embolism (n �7) Left-sided intracardiac mass (n �1) RA into RV Location RA (n �11) Vena cava (n �2) RA (n �11) SVC (n �17) SVC (n �13) (n �4) RV (n �3) PA (n �2) IVC (n �3) Vena cava (n �9) RA (n �31) RA (n �98) RA (n �1) TV/RV (n �11) TV (n �14) IVC (n �1) PA (n �1) RV (n �4) SVC (n �1) IVC (n �24) IVC (n �1) Infrailiac (n �8) Average size of the NA NA NA 4.1cm 3.2cm NA mass Proceduralsuccess 11 5 6 13 14 182 Transfusion Persistent or Postprocedural Hematoma Cardiogenic Bleeding (n �11) without overt recurrent Bleeding (n �9) complications (n �3) shock (n �1) bleeding (n �10) bacteremia (n �11) Pulmonary Transfusion Shock (n �5) Shock (n �1) embolism (n �8) (n �59) Persistent tricuspid Hemodialysis Hemodialysis Pulmonary regurgitation (n �3) (n �2) embolism(n �1) (n �19) Persistent Liver failure bacteremia (n �2) (n �1) Stroke (n �1) Hematoma (n �4) Arrhythmia (n �3) Average LOS 23 NA 20 13.82 16.84 NA Intraprocedural 13 7 7 14 57 231 survival Survival to 13 7 7 14 NA NA discharge IVC: inferior vena cava; IVDU: intravenous drug use; LOS: length of stay; PA: pulmonary artery; RA: right atrium; RV: right ventricle; SVC: superior vena cava; TV: tricuspid valve. 6 Journal of Interventional Cardiology Figure 2: Pre- and postprocedural transesophageal echocardiographic imaging of the removal of large thrombi via AngioVac. (a, c) Large vegetation across the mitral valve. (b, d) Near removal of multisegmented vegetation. (ere is good intraoperative success. AngioVac. Subsequently, more studies are required to de- Acknowledgments termine if AngioVac has a mortality benefit over surgical or (e authors thank the following from Aurora Cardiovas- medical management. cular and (oracic Services: Jennifer Pfaff and Susan Nord for editorial preparation of the manuscript and Brian 5. Conclusion Schurrer and Brian Miller for assistance with the figures. (e utility of the AngioVac System has been demonstrated in multiple case studies and in a few retrospective studies. References We have presented the experience with the system at our [1] K.K.Calder,M.Herbert,andS.O.Henderson,“(emortality institution, and though patients were critically ill with large of untreated pulmonary embolism in emergency department vegetative masses, our data demonstrate good intraoperative patients,” Annals of Emergency Medicine, vol. 45, no. 3, survival and success. Our data appear to further support the pp. 302–310, 2005. use of AngioVac in the cardiac catheterization laboratory as [2] A. Bariteau, L. K. Stewart, T. W. Emmett, and J. A. Kline, a treatment option for right heart masses in critically ill “Systematic review and meta-analysis of outcomes of patients patients with high surgical risk. Larger studies are required with subsegmental pulmonary embolism with and without to determine safety in large vegetations of use with right- anticoagulation treatment,” Academic Emergency Medicine, sided endocarditis. vol. 25, no. 7, pp. 828–835, 2018. [3] G. Behrens and H. Bjarnason, “Venous thromboembolic disease: the use of the aspiration thrombectomy device Data Availability AngioVac,” Seminars in Interventional Radiology, vol. 32, (e data used to support the findings of this study are no. 4, pp. 374–378, 2015. [4] T. M. Todoran, P. S. Sobieszczyk, M. S. Levy et al., “Percu- available from the corresponding author upon reasonable taneous extraction of right atrial mass using the Angiovac request. aspiration system,” Journal of Vascular and Interventional Radiology, vol. 22, no. 9, pp. 1345–1347, 2011. Consent [5] C. W. Donaldson, J. N. Baker, R. L. Narayan et al., “(rombectomy using suction filtration and veno-venous (e local institutional review board approved this study and bypass: single center experience with a novel device,” Cath- waived the requirement for informed consent. eterization and Cardiovascular Interventions, vol. 86, no. 2, pp. E81–E87, 2015. [6] J. M. Moriarty, R. Al-Hakim, A. Bansal, and J. K. Park, Conflicts of Interest “Removal of caval and right atrial thrombi and masses using (e authors declare no conflicts of interest. the AngioVac device: initial operative experience,” Journal of Journal of Interventional Cardiology 7 Vascular and Interventional Radiology, vol. 27, no. 10, pp. 1584–1591, 2016. [7] A. Al Badri, C. Kliger, and D. Weiss, “Right atrial vacuum- assisted thrombectomy: single-center experience,” Journal of Invasive Cardiology, vol. 28, no. 5, pp. 196–201, 2016. [8] N. Patel, T. Azemi, F. Zaeem et al., “Vacuum assisted vege- tation extraction for the management of large lead vegeta- tions,” Journal of Cardiac Surgery, vol. 28, no. 3, pp. 321–324, [9] R. Sakhuja, S. Gandhi, R. K. Rogers, R. J. Margey, M. R. Jaff, and R. Schainfeld, “A novel endovenous approach for treatment of massive central venous or pulmonary arterial thrombus, mass, or vegetation: the AngioVac Suction Can- nula and Circuit,” Journal of the American College of Car- diology, vol. 57, no. 14, Article ID E1535, 2011. [10] R. Chopard, F. Ecarnot, and N. Meneveau, “Catheter-directed therapyfor acutepulmonaryembolism:navigatinggaps inthe evidence,”EuropeanHeartJournalSupplements:Journalofthe European Society of Cardiology, vol. 21, no. 2, pp. I23–I30, [11] G. Gerosa, L. Longinotti, L. Bagozzi et al., “Transapical as- piration of a mitral mass with the AngioVac System on a beating heart,”e Annals of oracic Surgery, vol.110, no. 5, pp. e445–e447, 2020. [12] M.J.Robbins,R.W.M.Frater,R.Soeiro,W.H.Frishman,and J. A. Strom, “Influence of vegetation size on clinical outcome of right-sidedinfective endocarditis,”eAmericanJournalof Medicine, vol. 80, no. 2, pp. 165–171, 1986. [13] J. M. Moriarty, V. Rueda, M. Liao et al., “Endovascular re- movalofthrombusandrightheartmassesusingtheAngioVac System: results of 234 patients from the prospective, multi- center Registry of AngioVac Procedures in Detail (RAPID),” Journal of Vascular and Interventional Radiology, vol. 32, no. 4, pp. 549–557, 2021. [14] J. Salsamendi, M. Doshi, S. Bhatia et al., “Single center ex- perience with the AngioVac aspiration system,” CardioVas- cular and Interventional Radiology, vol. 38, no. 4, pp. 998–1004, 2015. [15] F. A. Rajput, L. Du, M. Woods, and K. Jacobson, “Percuta- neous vacuum-assisted thrombectomy using AngioVac as- piration system,” Cardiovascular Revascularization Medicine, vol. 21, no. 4, pp. 489–493, 2020. [16] J. M. Fallon, N. Newman, P. M. Patel et al., “Vacuum-assisted extraction of ilio-caval and right heart masses: a 5-year single center experience,” Journal of Cardiac Surgery, vol. 35, no. 8, pp. 1787–1792, 2020. [17] J. Bishara, L. Leibovici, D. Gartman-Israel et al., “Long-term outcome of infective endocarditis: the impact of early surgical intervention,” Clinical Infectious Diseases, vol. 33, no. 10, pp. 1636–1643, 2001. [18] F. Delahaye, R. Ecochard, and G. De Gevigney, “(e long- term prognosis of infective endocarditis,” European Heart Journal, vol. 16, pp. 48–53, 1995. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Interventional Cardiology Hindawi Publishing Corporation

Endovascular Treatment of Right Heart Masses Utilizing the AngioVac System: A 6-Year Single-Center Observational Study

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Copyright © 2021 Aashish Katapadi et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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Hindawi Journal of Interventional Cardiology Volume 2021, Article ID 9923440, 7 pages https://doi.org/10.1155/2021/9923440 Research Article Endovascular Treatment of Right Heart Masses Utilizing the AngioVac System: A 6-Year Single-Center Observational Study Aashish Katapadi , Lauren Richards , William Fischer , Suhail Q. Allaqaband , Tanvir Bajwa, and M. Fuad Jan Aurora Cardiovascular and oracic Services, Aurora Sinai/Aurora St. Luke’s Medical Centers, Advocate Aurora Health, 2801 W. Kinnickinnic River Parkway, Ste. 880, Milwaukee, Wisconsin 53215, USA Correspondence should be addressed to M. Fuad Jan; publishing18@aurora.org Received 12 March 2021; Revised 27 September 2021; Accepted 12 October 2021; Published 31 October 2021 Academic Editor: Michael C. Kim Copyright © 2021 Aashish Katapadi et al. (is is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Objective. To describe our institution’s experience with the AngioVac system.Background. Intracardiac and intravascular masses previously required surgical excision, but now, there are a number of minimally invasive options. With the advent of vacuum aspiration, more specifically the AngioVac System (AngioDynamics, NY, USA), there exists a system with both low mortality and minor complications. However, the number of retrospective studies remains limited. Outcome data for high-risk patients are also limited.Methods. Data were collected and analyzed in patients who underwent AngioVac therapy at our tertiary care center from January 2014 to December 2020.Results. Our results demonstrated a 93.3% intraoperative success rate and a 100% intraoperative survival rate. However, a number of complications, including but not limited to hematomas, anemia, and hypotension, occurred, as described below. Conclusions. Our experiences demonstrated good outcomes and continue to support the usefulness of the AngioVac System. (e data also support the use of AngioVac as a treatment option for the debulking or removal of right heart masses in critically ill patients. vegetations in the right atrium and ventricle, superior and 1. Introduction inferior vena cavae, and iliofemoral veins [3, 4]. (e system Intracardiac masses, specifically right-sided cardiac thrombi, has existed for a number of years, and its utility has been vegetations, and tumors, can be rare and life-threatening evaluated in a number of case studies [5–7]. However, data conditions and, moreover, are often difficult to manage. from recent clinical studies have remained limited or non- Mortality rates are often high in untreated patients [1, 2]. existent. Additionally, the AngioVac System has been con- Treatment options for these patients traditionally include sideredforoff-labeluseforavarietyofconditionsincludingas catheter-directed or systemic thrombolysis, embolectomy, an alternative to surgical thrombectomy in high-risk patients and medical management alone. Catheter-based suction for the removal or debulking of infectious vegetations and embolectomy has been successfully used for minimally in- benign or malignant tumors in the right atrium, ventricle, or vasive treatment of intravascular material. One such option is tricuspid valve. (ereare limiteddata regardingoutcomes for the AngioVac System (AngioVac Cannula and Circuit, these patients. Consequently, the purpose of this report is to AngioDynamics, NY, USA), a vacuum-assisted suction em- describe our institution’s experiences and outcomes with the bolectomy device designed to remove fresh thrombi and AngioVac System over the past 6 years. 2 Journal of Interventional Cardiology 2. Materials and Methods (e local institutional review board approved this study and AngioVac waived the requirement for informed consent. Cannula Saline 2.1. Study Population. All cases of AngioVac-assisted, catheter-based extraction techniques performed in the cardiac catheterization laboratory at our large tertiary care center from 2014 to 2020 were reviewed. (e deci- sion to proceed with AngioVac resulted from collabo- ration between multiple specialties (interventional cardiology, infectious diseases, and intensive care phy- sicians) and the patient; stability of the patient was also a consideration. Waste Bag Reinfusion Filter Cannula 2.2.AngioVacSystem. (e AngioVac System is a disposable intravenous system that is used with extracorporeal circu- latory support. It can be used to remove fresh, soft thrombi, emboli, or vegetations in the right atrium and ventricle, superior and inferior vena cavae, and iliofemoral veins. (e system consists of a 22-F AngioVac Cannula with a self- expanding tip that is used in conjunction with a reinfusion cannula as part of a bypass circuit (Figure 1). A centrifugal Centrifugal pump enables suction at the tip, which, when deployed Pump through either the internal jugular or femoral veins, enables removal of undesirable intravascular material. Figure1:AnoverviewoftheAngioVacreperfusionsystem.(etip (e system requires two venous access sites—1 for as- is inserted either via percutaneous or surgical cutdown at the piration and 1 for reperfusion—usually utilizing a combi- internal jugular or femoral vein and connected to a suction-gen- nationoffemoralorjugularveins.(eextracorporealbypass erating bypass circuit. Blood is filtered and reinserted at the circuit consists of an outflow line, a centrifugal pump, a reinfusion cannula. filter, and an inflow line. After venous access is obtained, the centrifugal pump is activated, creating a one-way flow that provides suction at the cannula tip. (e system has a bal- 3. Results loon-activated tip to augment venous flow and facilitate removal of the thrombogenic material into the filter. (e 3.1. Preoperative Characteristics. Demographic and preop- erative variablesarelistedinTables1and2,respectively.(e circuit reinfuses filtered blood back into the body through the reperfusion cannula to minimize blood loss (Figure 1). procedure was performed on a total of 17 patients, 10 fe- males and 7 males, with an average age of 47.1 years. In- dications for AngioVac were thrombus (35.3%, n �6/17), 2.3. Data Collection. Retrospective data from each patient, septic thrombus (5.9%, n �1/17), and endocarditis (58.8%, including demographics, medical history, treatment, pro- n �10/17). All patients were critically ill with high surgical cedural indication, procedural variables, imaging data risk.(eaveragesizeofthrombusorvegetationwas3.48cm, (transthoracic/transesophageal echocardiogram, computed all located on the tricuspid valve (47.1%, n �8/17) and right tomography, and magnetic resonance imaging), and both atrium with or without vena cava involvement (41.2%,n �7/ postoperative and long-term outcomes, were recorded. 17). A number of masses were mobile (64.7%, n �11/17). Importantly, intraoperative success was defined as complete Patients with endocarditis grew methicillin-susceptible removal of the mass or removal of >50% of the clot as seen Staphylococcus aureus (MSSA; 29.4%, n �5/17), methicillin- on intraprocedural transesophageal echocardiography and resistant Staphylococcus aureus (MRSA; 17.6%, n �3/17), per procedure note. Postprocedural echocardiography was Staphylococcus epidermidis (5.9%, n �1/17), and Entero- reviewed when available. coccus faecalis (5.9%, n �1/17). Pathologic examination of the extracted mass was not performed to confirm diagnosis (Tables 1 and 2). 2.4. Statistical Analysis. Results were reported for both quantitative and categorical variables. Results for quanti- tative variables were reported as median with interquartile 3.2. Postoperative Characteristics. Postoperative variables range, and those for categorical variables were reported as are listed in Table 3. (e procedure was successful in almost frequencies and percentages. all of the patients (94.1%, n �16/17), failing only once, in a Journal of Interventional Cardiology 3 Table 1: Demographics. Characteristics n (%) or median (IQR) Sex Male 7 (41.2) Female 10 (58.8) Average age (years) 47.1 (33–64) BMI 28.1 (21.1–32.9) History End-stage renal disease 1 (5.9) Coronary artery disease 4 (23.5) Valvular disease 2 (11.8) Prior thrombotic disease 1 (5.9) CHF 3 (17.6) Diabetes 2 (11.8) Hypertension 6 (35.3) Malignancy 4 (23.5) Iatrogenic immunosuppression 2 (11.8) Prior cardiac devices 2 (11.8) BMI: body mass index; CHF: congestive heart failure; IQR: interquartile range. Table 2: Preoperative variables. Indication n (%) or median (IQR) (rombus 6 (35.3) Septic thrombus 1 (5.9) Endocarditis 10 (58.8) Bacterial cultures Methicillin-sensitive Staph. aureus 5 (29.4) Methicillin-resistance Staph. aureus 3 (17.6) Staph. epidermidis 1 (5.9) E. faecalis 1 (5.9) Polymicrobial∗ 2 Location∗∗ SVC 1 (5.9) IVC/RA 2 (11.8) RA 5 (29.4) TV 8 (47.1) Average size 3.48 (2.25–4.7) Mobility Mobile 11 (64.7) Immobile 2 (11.8) LVEF 51.9 (42–60) Hemoglobin 9.1 (7.8–10.7) Creatinine 1.12 (0.67–0.98) ∗ ∗∗ Cultures include MRSA/Strep. gordonii and Enterobacter/Klebsiella/Citrobacter/Bacteroides. Multiple locations documented. IQR: interquartile range; IVC: inferior vena cava; LVEF: left ventricular ejection fraction; MRSA: methicillin-resistant Staphylococcusaureus; RA: right atrium;Staph:Staphylococcus; Strep: Streptococci; SVC: superior vena cava; TV: tricuspid valve. patient with infective endocarditis. Almost all patients cancer, was the cause of death in 2/17 who did make it to 1 (82.4%,n �14/17) survived to discharge and to 30 days after year (11.8%). Hematoma developed in 3/17 (17.6%) after hospitalization (76.5%, n �13/17). (e 3 patients who did AngioVac use. After the procedure, a number of patients not survive to discharge expired due to septic shock, severe developed hypotension (35.3%, n �6/17), with some re- metabolic derangements, and ruptured peptic ulcer leading quiring vasopressor support (11.8%, n �2/17) and some to respiratory failure. Of the 14 discharged, 4 had expired at requiringtransfusion(29.4%,n �5/17).Othercomplications 1 year, and 6 had not met the time requirements; the 1-year included worsening tricuspid regurgitation (5.9%, n �1/17), survival decreased greatly (23.5%, n �4/17). (e leading pulmonary embolism (5.9%, n �1/17), and formation of mycotic aneurysm (5.9%, n �1/17). (e average post- cause of in-hospital death was shock, both septic (11.8%, n �2/17) and cardiogenic (5.9%, n �1/17); malignancy, procedural hospital length of stay was 8.07 days, and many more specifically advanced stage glioblastoma and colon returned homefollowing their procedure (64.7%,n �11/17). 4 Journal of Interventional Cardiology Table 3: Postoperative variables. survival to discharge and 30-day survival were 82.4% and 76.5%,respectively.Immediatesuccessforthesepatientswas Variable n (%) or median (IQR) high andprovidedanopportunity toprolonglifeincritically Operative success 16 (94.1) ill patients without increasing mortality. Out of all the pa- Survival 17 (100.0) tients, 1-year survival greatly decreased to 23.5%. However, Survival to discharge 14 (82.4) itis importanttonotethat6patients hadnotyetmadeitto1 30-day survival 13 (76.5) year and another 3 did not survive hospitalization. Of the 4 One-year survival 4 (23.5) Average LOS 8.07 (3.0–10.0) who passed away, 1 was due to progressive failure to thrive Need for tPA 0 (0.0) postprocedure, 1 was due to severe septic shock with bac- Need for transfusion 5 (29.4) teremia, and 2 were due to advanced cancers, as discussed Need for hemodialysis 0 (0.0) previously. One procedure utilizing AngioVac was unsuc- LVEF∗ 57.5 (54.25–62.75) cessful and later required surgery for an infected thrombus Side effects∗∗ on an intracardiac lead. Only 2 patients did not survive to Hematomas 3 (17.6) discharge. Of these 2, 1 passed away due to cardiogenic Shock 1 (5.9) shock in the setting of severe tricuspid regurgitation and the Hypotension 6 (35.3) other due to severe septic shock. (ough both patients had Vasopressor use 2 (11.8) moderate-sized masses and met intraoperative success, they Hemoglobin 8.7 (7.4–9.5) remained critically ill following the procedures. (e patients Creatinine 1.09 (0.63–1.15) ∗ ∗∗ who did survive past 1 year appeared to do well with no Nine patients missing postoperative LVEF. Other side effects were worseningtachycardia,PE,mycoticaneurysm,intraoperativeSVT,needfor sequelae of endocarditis. Unfortunately, many patients with intubation (2), and need for the IVC filter. IQR: interquartile range; IVC: infective endocarditis did relapse or continue using intra- inferior vena cava; LOS: length of stay; LVEF: left ventricular ejection venous drugs. (is highlights both the severity of substance fraction; PE: pulmonary embolism; SVT:supraventriculartachycardia; tPA: abuse, especially intravenous drug use, and difficulties of tissue plasminogen activator. treating this patient population. Complications most noted were hematoma at the site of catheter insertion, acute anemia requiring transfusion, and 4. Discussion persistent hypotension. Other notable complications, Strategies for intravascular or intracardiac masses tradi- though only occurring in 1 patient each, were worsening tionally revolve around anticoagulation, thrombolysis, and tricuspid regurgitation, supraventricular tachycardia and surgical interventions. In patients for whom thrombolysis is sinus tachycardia, and pulmonary embolism and mycotic contraindicated, surgical therapy such as embolectomy is an aneurysms. option. (e introduction of catheter-based rheolytic and (ere continues to exist a small number of retrospective aspiration technologies such as AngioVac offers an alter- studies involving the AngioVac System. More recently, a large registry with 234 concomitant procedures demon- native, minimally invasive approach to thrombectomy with low morbidity. AngioVac, in particular, has the advantage of strated the safety of the AngioVac System, with only 3 procedure-related deaths. (e indication for the procedure whole, intact thrombus aspiration. (is approach also de- creases the number of complications in an already high-risk was a right heart mass in 52.6% of cases; intraprocedural success, defined as >70% mass removal, was achieved in patient population. Although AngioVac is US Food and Drug Administration-approved only for thrombi and em- nearly 60% of patients with right heart masses [13]. Our own boli, this benefit makes it appealing for use with additional results coincide with previously published data, as seen in indications. Table 4, demonstrating good intraoperative success While the earliest literature referencing the AngioVac [5, 7, 14–16]. Likewise, these results also support the use of System describes the percutaneous extraction of a 1.7cm AngioVacasatreatmentoptionforcriticallyillpatientswith right atrial mass in the setting of endocarditis, the device has right-sided heart masses, as seen in Figure 2. Short-term success and survival rates are high. Information about long- been utilized on vegetations on implantable cardioverter- defibrillatorleadsandpermanentpacemakerswithasurvival term outcomes in those who undergo the AngioVac pro- cedure does not currently exist. Patients with infective benefit [4, 8]. (e variety of indications has continued to grow as cases have been added to the literature [9–11]. endocarditis have only 50% survival at 10 years, with the Patients treated for infective endocarditis with large vege- highest survival rate in people who undergo early surgery tations (>10mm) with clinical evidence of embolic phe- [17, 18]. (e AngioVac procedure provides life-prolonging nomena are often critically ill and carry a high perioperative measures otherwise unavailable for patients who may oth- risk foropen cardiacsurgery [12].AlthoughAngioVacis not erwise not live to discharge. (is supports the idea that yet approved for the debulking of infectious vegetations, it vacuum-assisted thrombectomy, specifically AngioVac at has been used for patients in inoperable situations in which this time, should be used in the algorithm for right-sided mortality is almost certain without further treatment. cardiac masses. Despite promising results at 30 days, the data are limited Our own data are characterized by use of AngioVac in a similar population and in the cardiac catheterization labo- by study size at a single center, and a larger patient pop- ulation is necessary. Additionally, there are no prospective ratory. Procedural success and procedural survival in this populationwere94.1%and100%,respectively.Furthermore, studies comparing surgery or medical management to Journal of Interventional Cardiology 5 Table 4: Prior retrospective studies. Donaldson et al. Salsamendi et al. Moriarty et al. AlBadrietal.[7] Rajput et al. [15] Fallon et al. [16] [5] [14] [13] Year 2015 2015 2016 2020 2020 2021 Patients (n) 15 7 7 16 58 234 Mean age (years) 50 49.6 51.5 48 48 50.8 Female sex (n) 3 4 5 12 27 111 Right-sided Right-sided Caval thrombus Caval thrombus IVC-associated Sterile thrombus Indication intracardiac mass intracardiac (n �11) (n �2) mass (n �3) (n �30) (n �11) mass (n �123) Catheter- Fontan conduit Pulmonary Catheter- Cardiac device- Pulmonary associated and Glenn shunt embolism associated associated embolism (n �5) thrombus mass (n �1) (n �2) thrombus (n �7) vegetation (n �8) (n �25) Catheter- Catheter- Chronic vascular Intracardiac mass associated Caval thrombus Caval thrombus associated access-associated (n �4) thrombus (n �9) (n �91) thrombus (n �2) vegetation (n �16) (n �2) Concurrent IVDU-related Pulmonary pulmonary vegetation (n �4) embolism(n �7) embolism (n �7) Left-sided intracardiac mass (n �1) RA into RV Location RA (n �11) Vena cava (n �2) RA (n �11) SVC (n �17) SVC (n �13) (n �4) RV (n �3) PA (n �2) IVC (n �3) Vena cava (n �9) RA (n �31) RA (n �98) RA (n �1) TV/RV (n �11) TV (n �14) IVC (n �1) PA (n �1) RV (n �4) SVC (n �1) IVC (n �24) IVC (n �1) Infrailiac (n �8) Average size of the NA NA NA 4.1cm 3.2cm NA mass Proceduralsuccess 11 5 6 13 14 182 Transfusion Persistent or Postprocedural Hematoma Cardiogenic Bleeding (n �11) without overt recurrent Bleeding (n �9) complications (n �3) shock (n �1) bleeding (n �10) bacteremia (n �11) Pulmonary Transfusion Shock (n �5) Shock (n �1) embolism (n �8) (n �59) Persistent tricuspid Hemodialysis Hemodialysis Pulmonary regurgitation (n �3) (n �2) embolism(n �1) (n �19) Persistent Liver failure bacteremia (n �2) (n �1) Stroke (n �1) Hematoma (n �4) Arrhythmia (n �3) Average LOS 23 NA 20 13.82 16.84 NA Intraprocedural 13 7 7 14 57 231 survival Survival to 13 7 7 14 NA NA discharge IVC: inferior vena cava; IVDU: intravenous drug use; LOS: length of stay; PA: pulmonary artery; RA: right atrium; RV: right ventricle; SVC: superior vena cava; TV: tricuspid valve. 6 Journal of Interventional Cardiology Figure 2: Pre- and postprocedural transesophageal echocardiographic imaging of the removal of large thrombi via AngioVac. (a, c) Large vegetation across the mitral valve. (b, d) Near removal of multisegmented vegetation. (ere is good intraoperative success. AngioVac. Subsequently, more studies are required to de- Acknowledgments termine if AngioVac has a mortality benefit over surgical or (e authors thank the following from Aurora Cardiovas- medical management. cular and (oracic Services: Jennifer Pfaff and Susan Nord for editorial preparation of the manuscript and Brian 5. Conclusion Schurrer and Brian Miller for assistance with the figures. (e utility of the AngioVac System has been demonstrated in multiple case studies and in a few retrospective studies. 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Published: Oct 31, 2021

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