Invasive Hepatocellular Carcinoma With Recurrent Pulmonary Embolism: Use of AngioVac CannulaThrombectomy Device for Mechanical Aspiration

ABSTRACT: Right atrial and vena cava thrombus is a challenging clinical problem with limited treatment options for percutaneous extraction. We describe the use of a novel AngioVac venous extracorporeal bypass system (AngioDynamics) to remove a part of large right atrial tumor and thrombus in a patient with recurrent pulmonary embolism from hepatocellular carcinoma infiltrating into the inferior vena cava and the right atrium.

J INVASIVE CARDIOL 2014;26(7):E100-E103

Key words: thrombectomy, pulmonary embolism

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Case Report. A 44-year-old man with no significant past medical history presented with chest pain and shortness of breath. A computerized tomogram (CT) done in the emergency room confirmed the diagnosis of right segmental and left subsegmental pulmonary embolism (PE). In addition, a right liver mass was partially seen on the CT scan. The patient received enoxaparin as a bridge to coumadin and was advised to follow up on the liver mass as an outpatient. The alpha fetoprotein was 7.2 ng/mL (normal, <8.5 ng/mL) and his blood tests were negative for hepatitis B or C. Four weeks later, the patient had a magnetic resonance imaging (MRI) of his abdomen that confirmed a 5.6 x 7.6 x 5.5 cm mass involving hepatic segments VI and VII. Liver biopsy was scheduled  as an outpatient for definitive diagnosis. However, the patient presented again to the emergency room with right pleuritic chest pain and worsening shortness of breath. On examination, the patient had a blood pressure of 115/70 mm Hg, a heart rate of 91 beats/min, and a respiratory rate of 24 breaths/min with 90% saturation on room air. His jugular venous pressure was normal. Lung examination revealed bilateral decreased air entry at the bases without crackles. Cardiac examination showed normal first and second heart sounds with no murmurs. He had no edema or tenderness of his legs. The patient was compliant with coumadin with an international normalized ratio (INR) of 3 at presentation. A repeat CT scan at this time showed extension of his bilateral segmental and subsegmental pulmonary emboli with new emboli. A retrievable inferior vena cava (IVC) filter was placed due to recurrent PE in a patient on anticoagulation. A CT angiogram of the abdomen done as part of hepatic mass work-up showed an extensive tumor in the right hepatic lobe with extension into the IVC (Figure 1). An echocardiogram did not show any right ventricular dysfunction at this time, but did confirm the 6 x 2 cm mobile right atrial mass attached to the IVC (Figures 2A and 2B). Leg venous duplex did not show any evidence for deep venous thrombosis (DVT). The patient was switched to intravenous heparin and underwent biopsy of the liver mass, which confirmed the diagnosis of hepatocellular carcinoma (HCC). While awaiting further management plan for his HCC, the patient became short of breath, requiring 50%-100% FiO₂ with a non-rebreather mask. He was tachycardic, but still maintained systolic blood pressure of 104 mm Hg. This worsening in his respiratory status was thought to be due to recurrent embolization from the tumor clot.

Given recurrent pulmonary embolism and tenuous respiratory status secondary to likely tumor clot burden, options were limited. The patient was not considered a surgical candidate for thrombectomy due to his unresectable HCC and multiple bilateral emboli. Also, catheter directed or systemic thrombolysis was expected to be less successful as the atrial mass and emboli were likely to be tumor clot. The patient agreed to proceed with mechanical thrombectomy of the mobile right atrial mass using the AngioVac cannula thrombectomy catheter (AngioDynamics; Figure 3).

Procedure. The procedure was done using general anesthesia. Given prior IVC filter and inability to retrieve the filter due to tumor mass in the suprarenal IVC, a 26 Fr Gore dry-seal sheath for the inflow cannula was placed percutaneously in the right internal jugular vein and another 26 Fr Gore dry-seal sheath for the return cannula was placed in the right femoral vein. Intravenous heparin was used for anticoagulation to achieve an activated clotting time of over 300 seconds. Transesophageal echocardiogram was used to guide catheter position in the right atrium. The AngioVac cannula was then advanced over a 0.035˝ guidewire into the right atrium above the tumor mass and the catheter tip funnel actuated (Figures 4A and 4B). The perfusion circuit was then purged of any air and aspiration thrombectomy was performed with successful removal of the mobile component of the right atrial mass. There was no significant arrhythmia during activation of the device in the right atrium. The IVC and fixed right atrial mass were part of the invasive HCC and could not be aspirated. Both the aspirated fluid and fragments were sent to pathology. The access sheaths were removed and hemostasis was achieved with percutaneous skin sutures and manual compression. The patient tolerated the procedure well without complications.

The mobile fragment aspirated was 7 x 6 x 4 mm and its histology was consistent with a recent thrombus. The cytology of the fluid aspirated with the cannula had HCC cells, thereby confirming presence of both tumor cells and superimposed blood clot. He did not have any further recurrence of his embolic episodes during hospitalization. Further treatment options were discussed by the oncology service with the patient. Due to advanced non-resectable HCC, the patient was treated with anticoagulation with subcutaneous enoxaparin and oral sorafenib. The patient was discharged home with hospice care and therefore no further imaging was obtained. The patient did not respond to sorafenib and died after 2 months. 

Discussion. HCC is an aggressive tumor with potential for invasion of portal and hepatic veins. Advanced HCC with invasion of IVC and right atrium is uncommon, but associated with very poor prognosis with limited treatment options. In a retrospective study of 50 patients with advanced HCC with right atrial involvement, the median survival was only 2 months with supportive care and only marginally improved to 4 months with aggressive therapies.¹ The current American Association of Liver Diseases guidelines recommend palliative therapy for patients with Barcelona Clinic Liver Cancer Group (BCLC) stages C and HCC.²  However, due to recurrent pulmonary embolism and progressive hypoxemia in our patient, the decision was made to attempt  mechanical thrombectomy to prevent further respiratory deterioration. In retrospect, the decision to place an IVC filter early during his second admission was inappropriate, because the patient did not have any evidence of deep venous thrombosis and the filter did not offer any protection from the tumor emboli.

There were limited options for mechanical thrombectomy in this case and surgical resection was not possible; hence, the AngioDynamics AngioVac catheter was used. The AngioVac catheter (Figure 3) is a large-bore (22 Fr) aspiration catheter with a balloon-actuated tip that uses a perfusion circuit to allow for forceful en bloc aspiration of clot or intravascular thrombus. The AngioDynamics Medical AngioVac Cannula is Food and Drug administration (FDA) cleared for use as a venous drainage cannula during extracorporeal bypass for up to 6 hours. The use of the AngioVac aspiration system has been described in several case reports in a variety of clinical settings, including massive or submassive pulmonary embolism, right atrial masses (thrombus or vegetation), and IVC of iliac thrombus.^3-5 However, there are limited data on the efficacy of the AngioVac Vortex catheter.⁶ The main advantage of the catheter is its ability to aspirate large amount of thrombus without the use of adjunctive thrombolysis. However, it does require two large-bore intravenous access sites, is not very easy to manipulate, and is limited in its role beyond the lobar pulmonary arteries due to difficulty with catheter manipulation and large catheter size. The catheter use also requires general anesthesia and a cardiac perfusionist. While there are several devices used for mechanical thrombectomy and catheter-directed thrombolysis (Table 1), the AngioVac cannula is a niche device for select patients with a large amount of thrombus burden in the venous system and the right atrium. More data are needed to compare its efficacy compared to other thrombectomy devices and for evaluation of its impact on patient outcomes. This report describes the use of this novel catheter in a patient with extensive hepatocellular carcinoma with right atrial extension and recurrent pulmonary embolization.

References

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From the Heart & Vascular Center, MetroHealth Campus – Case Western Reserve University, Cleveland, Ohio.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein.

Manuscript submitted September 4, 2013, provisional acceptance given September 23, 2013, final version accepted November 11, 2013.

Address for correspondence: Sanjay Gandhi, MD, FACC, FSCAI, FAHA, Director of Endovascular Cardiology, Associate Professor of Medicine, MetroHealth Campus, Case Western Reserve University, Cleveland, OH 44109. Email:  sgandhi@metrohealth.org