Transcatheter vacuum-assisted aspiration of large intracardiac and intravascular masses

Abstract

Intravascular and intracardiac masses are usually represented by thrombi, tumours, and vegetations. They can affect both the right and left chambers of the heart and the venous and arterial circulation. Traditionally, their treatment is surgical or, in some circumstances, based on systemic anticoagulation/fibrinolysis. However, the complexity and frailty of patients who sometimes present with these conditions have pushed surgeons to find alternative minimally invasive effective treatments. While small masses can be removed with multiple devices, large masses are a more challenging problem. Vacuum-assisted aspiration systems such as the AngioVac System were developed to treat intravenous and right-sided heart thrombi. The application of the AngioVac System was widened to right-sided endocarditis and, later, to left-sided thrombi and vegetations. This review summarises the clinical results of different uses of the vacuum-assisted aspiration system to treat intravenous and intracardiac masses.

Figure 1. Standard cannulation setup.

The aspiration cannula (aC) is inserted into the venous system through the femoral vein (FV). Thrombi and/or vegetations are aspirated with the venous blood and trapped in the filter (F). Filtered blood is then circulated by a console-controlled (C) centrifugal pump (P) and returned to the patient through the reinfusion venous cannula (rC) in the jugular vein (JV). The represented setup includes three shunting lines: the first one (Sh1) to bypass the filter, the second one (Sh2) to include an oxygenator (Ox) and the third one (Sh3) to exclude the whole circuit from the patient. R: right side; L: left side

Figure 2. Available AngioVac inflow cannulae.

A) 22 Fr size with a 180° angle tip, (B) 22 Fr size with a 20° angle tip, and (C) 18 Fr size with an 85° angle tip.

Figure 3. Superior vena cava-right atrium thrombus.

Patient with port-a-cath thrombosis. A) The aspirated thrombus is extracted from the funnel-shaped tip of the AngioVac cannula. B) The entire thrombus is shown, measuring over 10 cm.

Figure 4. Inferior vena cava thrombus/tumour infiltration.

The patient was affected by kidney carcinoma and inferior vena cava neoplastic infiltration and thrombosis. A) Filter containing the aspirated material; (B) fragments of the intravenous mass.

Figure 5. Tricuspid endocarditis.

The filter containing the suctioned vegetation.

Figure 6. Native mitral valve endocarditis.

Transapical aspiration access and femoral artery reinfusion. A,B) Preoperative 2D/3D TOE: vegetation attached to the posterior mitral leaflet and floating in the left atrium during systole (red arrow). C,D) Postoperative 2D/3D TOE: the vegetation is almost completely removed (red arrow). 2D: two-dimensional; 3D: three-dimensional; TOE: transoesophageal echocardiography

Figure 7. Massive pulmonary embolism.

A) Preprocedural angio-CT: the principal pulmonary branches show almost complete occlusion. B) Postprocedural angio-CT: almost complete reperfusion is appreciable on both sides. CT: computed tomography

Figure 8. Mitral and aortic prosthesis endocarditis.

Transapical aspiration access and femoral artery reinfusion. A) 2D preoperative transoesophageal echocardiography (TOE) showing the presence of a mass (red arrow) attached to the aortic prosthesis and floating in the aortic root, (B) 2D preoperative TOE showing a mass (red arrow) attached to the mitral prosthesis on the atrial side, (C) postoperative 2D TOE showing no residual mass on the aortic prosthesis, (D) postoperative 2D TOE showing a residual minimal stump (red arrow) on the mitral prosthesis. 2D: two-dimensional

Central illustration. Circuit setups.

A) Right-sided masses. A1) Jugular vein – femoral vein access: superior caval, tricuspid, atrial and jugular vein mass suction. This is preferable to treat haemodynamically stable patients, since the reinfusion cannula is positioned in the femoral vein, and therefore, there is no chance to mechanically assist the patient. A2) Femoral vein – femoral artery access ECMO configuration: right-sided masses suction and circulatory assistance. A shunt line allows for filter bypassing, in case of need for assistance >6 h. A3) Pulmonary artery – femoral vein access±oxygenator: for pulmonary embolism. By switching the reinfusion cannula into the femoral artery, the system can be shifted to a temporary ECMO. A4) Pulmonary artery – femoral artery access ECMO configuration: this configuration enables the operator to treat pulmonary embolism, ensuring mechanical support to the circulation. The oxygenator and the shunt line provide the chance to bypass the filter in case of need for >6 h of use, transforming the circuit into an ECMO. B) Left-sided masses. B1) Femoral artery – femoral vein access: this configuration has been described for abdominal aorta mass suction procedures. B2) Transseptal – femoral artery access±oxygenator: this setup has been described to approach left atrial/mitral valve/LV masses. The optional use of an oxygenator increases the filtering and assists blood oxygenation in case the patient needs prolonged mechanical circulatory support; in this case, a shunt line allows for filter bypassing and prolonged left mechanical assistance. B3) Transapical – femoral artery access±oxygenator: mitral and aortic valve masses. This setup includes two shunt lines: one to bypass the filter in case of need for prolonged left mechanical assistance and one to allow the potential use of an oxygenator. B4) Transapical – subclavian artery access±oxygenator: the reinfusion cannula can be positioned in the subclavian artery when femoral arteries are not available. This configuration allows for prolonged left mechanical assistance by means of a shunt line bypassing the filter. ECMO: extracorporeal membrane oxygenation; LV: left ventricular