From the Guidelines
The AngioVac system is primarily indicated for the removal of unwanted intravascular material, such as fresh, soft thrombi or emboli, in the venous system, right heart, and pulmonary arteries, particularly for large-volume clot burden that may be difficult to treat with conventional therapies. The indications for AngioVac include:
- Right atrial or ventricular thrombi
- Inferior vena cava thrombi
- Iliofemoral deep vein thrombosis
- Pulmonary emboli
- Vegetation removal from cardiac devices or valves
- Tumor thrombi As reported by the American Heart Association in 2019 1, AngioVac thrombectomy in the PAs has been associated with hemodynamic collapse and RV free wall perforation, highlighting the need for careful patient selection and specialized training. The procedure involves a veno-venous bypass circuit where blood is removed through a large-bore cannula, filtered to remove unwanted material, and then returned to the patient. AngioVac is typically considered when traditional anticoagulation therapy is contraindicated, has failed, or when there is a high risk of complications from standard therapies, as seen in the largest systematic review of AngioVac use, which described access-site hematomas, fatal retroperitoneal bleed, and ICH in some patients 1. Potential complications include vascular injury, bleeding, hemolysis, and air embolism, so patient selection is crucial, and the procedure requires specialized training and equipment, including cardiac surgery backup, and is generally performed in a hybrid operating room or cardiac catheterization laboratory. Recovery time varies based on the underlying condition, but most patients require 24-48 hours of monitoring post-procedure. It is essential to weigh the benefits and risks of AngioVac use, considering the potential for hemodynamic collapse and other complications, as reported in the MAUDE database search, which revealed 34 cases of hemodynamic collapse related to the AngioVac device 1.
From the Research
Indications for Angiovac
- Intracardiac mass 2, 3
- Caval thrombus 2, 4
- Catheter-associated thrombus 2
- Pulmonary embolism (PE) 2, 4, 5
- Endocarditis 4, 3
- Deep vein thrombosis (DVT) 4, 3, 6
- Right-sided vegetations and right atrial/caval venous thrombi 4
- Septic emboli 3
- Cardiac masses 3
Patient Selection
- Patients who are poor candidates for surgical embolectomy or thrombolytic therapy 2
- Patients with large central thrombi or masses in-transit who are at risk of complicated PE 2
- Patients with right-sided endocarditis requiring vegetation debulking, intravascular thrombi, or cardiac masses 3
- Patients with iliofemoral DVT and long life expectancy 6
- Patients with acute limb-threatening venous occlusion or severe symptoms from DVT 6