**3. Evolving percutaneous options for treatment**

Given that 10–15% of patients fail medical therapy, percutaneous treatment options as an adjunct to medical therapy have now started to become mainstream. Specifically, the use of AngioVac device (AngioDynamics, Latham, New York) has begun to get traction because of its ease of use, low risk profile and ability to debulk the vegetation and prevent septic pulmonary emboli. The AngioVac system is a veno-venous extracorporeal system. The most common configuration is as a bilateral femoral venous platform or via the right internal jugular and femoral platform. The system mainly consists of a cannula and a circuit along with a trap, which captures the undesirable material. AngioVac is currently used in the setting of thromboembolic disease, particularly in the vena cava or the right atrium. Both the cannula and circuit are indicated for use in procedures requiring extracorporeal circulatory support for periods up to six hours for removal of fresh, soft thrombi or emboli. The cannula and circuit are designed to be used with off shelf pump, filter and reinfusion cannula. The device itself leverages the use of blood flow through a centrifugal pump to create negative pressure in order to extirpate undesirable intravascular material, such as thrombus, emboli or vegetation.
