Treatment of a huge femoral artery pseudoaneurysm with a suture based vascular closure device

This case was originally published on Twitter by @sulimov_dmitry via #CardioTwitterCase

Clinical presentation

An 83-year old woman underwent transcatheter aortic valve implantation (TAVI) via right femoral access. A 6F left femoral access was used for aortic root angiography and was closed using a plug-based vascular closure device (FemoSeal, Terumo, Japan). Three days after TAVI, a vascular ultrasound revealed a huge femoral pseudoaneurysm originating from the left common femoral artery. The aneurysm size was 5x3x2.5 cm, the wall defect diameter was 2 mm and located on 12 o’clock, and the neck was straight and 1 cm long. Manual compression for 30 minutes did not cause thrombosis of the aneurysm. Due to high retrograde flow through the neck we refrained from ultrasound-guided thrombin injection because of the risk of embolization and the possible need of a high thrombin volume, and decided for interventional treatment of the aneurysm.

Case Management

The procedure was performed using right femoral access. After angiography, an ultrasound-guided puncture of the neck of the aneurysm was performed (the needle was directed towards the orifice of the aneurysm using ultrasound). After a short attempt, we succeeded in wiring the femoral artery through the neck and wall defect and confirmed the position of the wire angiographically. A 6F introducer sheath was inserted over the wire and the orifice of the pseudoaneurysm was closed using a suture-bases vascular closure device (Perclose ProGlide, Abbott, USA) with immediate closure of the wall defect.
The suture-based vascular closure device was chosen because of the possibility to leave the wire in the artery after aneurysm closure. This would have enabled the use of other or additional vascular closure devices in case of failure of the first one.

A contralateral vascular access remains necessary for this technique, because fresh pseudoaneurysms have no resistant walls and bleeding into the surrounding tissue starts as soon as they are punctured. In case of difficult wiring or significant bleeding the iliac artery can be temporary occluded with a balloon through the contralateral access.
The technique was previously described by Ibrahim K. et al¹ and modified by Mizin A. and Terekhin S.² In this case, we used the original technique because of the known simple anatomy of the aortic bifurcation and the simplicity of bail-out options.

References

1. Ibrahim K, Christoph M, Wunderlich C, Jellinghaus S, Loehn T, Youssef A, Schoener L, Quick S, Mierke J, Strasser RH, Pfluecke C. A novel interventional method for treating femoral pseudoaneurysms: results from a monocentric experience. EuroIntervention. 2017 Jun 20;13(3):366-370. doi: 10.4244/EIJ-D-16-00865. PMID: 28394757.
2. Terekhin S., Mizin A., Zakharov A., Melkozerov K., Marchenko O., Kalashnikov V., Dedov I., Endovascular closure of iatrogenic femoral arterial pseudoaneurysm using radial access and Angio-Seal vascular closure device. Oral presentation during EuroPCR 2018

Original tweet and Twitter discussion

Huge femoral pseudoaneurysm 3 days after 6F vascular acces, initialy closed with plag-based VCD. 5x3x2,5 cm. The neck Was quite short with 1 cm and relatively straight. Interventional treatment see below pic.twitter.com/KZ7XS0tU1c

— Dmitry Sulimov (@sulimov_dmitry) October 6, 2020