Interventional extraction of a tumor mass from the aortic arch using a snare and aspiration thrombectomy system

Background
The extraction of intracardiac or intravascular masses is typically performed surgically. However, in patients for whom surgery is not feasible, interventional removal may be indicated.

Case report
A 47-year-old male patient was referred to our clinic following a severe stroke, which presented as right-sided hemiparesis, neglect, and global aphasia. A cranial CT scan revealed a large middle cerebral artery stroke, and the patient was subsequently referred for interventional therapy. Cerebral angiography identified thrombotic occlusion of the middle cerebral artery and partial occlusion of the internal carotid artery, which was treated with thrombectomy using an aspiration catheter and a stent retriever (Figure 1). The following day, the patient developed cerebral edema, necessitating decompressive craniotomy to relieve intracranial pressure. Although the patient was stabilized, a follow-up CT scan revealed secondary bleeding in the infarcted area, which was managed conservatively.

A CT scan of the aorta identified a large structure in the aortic arch, suspected as a possible source of embolic stroke. A thrombus or primary malignancy was considered. Whole-body CT scanning found no malignancy in other organs, although a small embolic infarction in the spleen was detected. Transesophageal echocardiography (TOE) showed a mobile structure measuring approximately 3 x 2 x 0.8 cm, originating from the aortic wall in the aortic arch (Figure 2). Given the high mobility of this structure and the associated risk of further embolization, as well as the need for histological analysis, removal was indicated. However, due to the patient's critical condition and contraindications for extracorporeal circulation stemming from the cerebral bleed, surgical removal was ruled out. Thus, an interventional approach to remove the structure was planned.

Initially, a cerebral protection device was deployed through the right radial artery. A 24 French and a 16 French sheath were placed in the right and the left femoral arteries respectively. An endoscopic snare was deployed in the descending aorta through 16 F sheat. A 24 French aspiration thrombectomy system was then advanced into the descending aorta through the endoscopic snare, with a secondary snare inserted through the aspiration system. The catheter was positioned adjacent to the structure, and under TOE guidance, the structure was snared through the catheter. The catheter was then advanced over the snare toward the structure, and aspiration was applied.

When the structure did not detach, the previously placed endoscopic snare was advanced over the aspiration catheter to the aortic wall, where the structure was anchored. The endoscopic snare was then closed, detaching the structure from the aortic wall. Subsequently the structure could be fully aspirated into the catheter (Figure 3). Three fragments of the solid tumor were retrieved from the catheter for histological analysis (Figure 4, results were pending at the time of this abstract). TOE revealed only minimal rest of the structure on the aortic wall (Figure 5). The cerebral protection device was removed, with no embolic material detected. No complications occured during or after the procedure.

Conclusion
We present a challenging case of the interventional removal of a large intravascular mass from the aortic arch. Using a cerebral protection system, aspiration thrombectomy catheter, and dual snares, we successfully extracted the structure.