Keywords
Amplatzer - Angio-Seal - common femoral artery - iatrogenic - pseudoaneurysm
Introduction
Femoral artery pseudoaneurysm is a well-known complication of angiography and transfemoral
interventions, particularly with low punctures, with a reported incidence of between
0.2 and 7%.[1] It is postulated that the formation of these pseudoaneurysms are related to the
severe calcification of these arteries preventing vessel wall healing post cannulation.[2]
Direct thrombin injection is a widely accepted and generally a safe method of treating
these pseudoaneurysms in a minimally invasive fashion. However, several fatal complications
have been reported, with a failure rate of between 4 and 9%.[3] The risk of microembolization is directly related to the length of the channel between
artery and pseudoaneurysm.[4]
The other proposed methods of treating these pseudoaneurysms include ultrasound-guided
compression,[5] selective embolization of the neck with n-butyl cyanoacrylate [6] or coil embolization,[7] stent grafts deployment,[8] and surgical repair.[9] In recent times, there were several case reports [10],[11],[12] describing a novel technique of treating these pseudoaneurysms via retrograde deployment
of an Angio-Seal vascular closure device with considerable success and safety.
In this report, we present a case of a femoral pseudoaneurysm repair using Amplatzer
vascular plugs following several unsuccessful attempts of retrograde approach through
the neck of the pseudoaneurysm via wire capture technique and deployment of Angio-Seal
(St Jude Medical, St Paul, MN, USA) vascular closure device.
Case Report
A 65-year-old man with a background of sarcoidosis presented with an acute myocardial
infarction and underwent emergency percutaneous coronary intervention and revascularization
of his left anterior descending artery with an 8-Fr sheath access of the right common
femoral artery. The patient was anticoagulated with unfractionated heparin during
the procedure. The intervention went uneventfully and the arteriotomy site was closed
with an Angio-Seal vascular closure device. The patient recovered well and was discharged
after 2 days and was commenced on dual antiplatelet therapy.
One week following his cardiac intervention, he was noted to have a pulsatile mass
in his right groin with an associated bruit. He underwent a Duplex arterial ultrasound
scan, which showed a bilobed pseudoaneurysm (superficial aneurysm measures 20 mm in
transverse diameter with a shallow neck 0.8 mm; deep aneurysm measures 12 mm in transverse
diameter which extends off a 6 mm neck) arising just lateral to the femoral artery
puncture site [Figure 1]A.
Figure 1 (A-D): (A) Bilobed pseudoaneurysm arising from the right common femoral artery seen on Duplex
ultrasound. (B) Ultrasound-guided thrombin injection with successful sealing of the
superficial component of the pseudoaneurysm. (C) Demonstration of persistent flow
in the deep component of the pseudoaneurysm on Duplex ultrasound; (D) Successful embolization
with no flow within the pseudoaneurysm post Amplatzer plug deployment
He went on to have an ultrasound-guided percutaneous injection of the pseudoaneurysm
with thrombin. The procedure proved to be extremely challenging due to rapid blood
flow and the wide pseudoaneurysm neck (6 mm). Following 10 min of direct sonographic
probe pressure, complete occlusion of the superficial pseudoaneurysm was observed
but a small residual fleck of flow on power Doppler was evident to suggest an incomplete
occlusion of the deep component of the pseudoaneurysm [Figure 1]B. This was confirmed on repeat Duplex ultrasound scan the following day [Figure 1]C.
The patient refused surgical repair and was offered a novel approach using an Angio-Seal
vascular closure device. Informed consent was obtained from the patient for the “off-label”
use of this device. A 6-Fr contralateral sheath was positioned in the distal right
external iliac artery from the left common femoral artery and angiography was performed
which demonstrated the pseudoaneurysm arising from the anterolateral aspect of the
right common femoral artery [Figure 2]A. Percutaneous right access of pseudoaneurysm was achieved using a wire capture
technique. The pseudoaneurysm neck was catheterized and the catheter directed anteriorly.
A 0.014-inch straight wire was advanced into the wall of the pseudoaneurysm, which
acted as a marker to the location of the pseudoaneurysm neck. A parallax was formed
via multiple projections based on the straight wire to guide the entry point of the
micropuncture needle at the skin surface. An 18G × 15 cm needle was inserted percutaneously,
and advanced with rotation in order to engage the straight wire end [Figure 2]B. Following successful wire capture, a 0.014-inch wire was advanced through the
18G needle and a 5-Fr microsheath was inserted over the wire into the right external
iliac artery. This allowed a 0.035-inch wire to be advanced through the sheath into
the right external iliac artery. An 8-Fr Angio-Seal device was inserted in a retrograde
manner ensuring that the polymer anchor is pulled firmly against the neck of the pseudoaneurysm.
The toggle of the Angio-Seal device failed to hold at the artery wall. The procedure
was repeated with a similar result. It was thought that the wide pseudoaneurysm neck
was the reason for the failure of Angio-Seal deployment. A decision was made to use
an Amplatzer 4 (St Jude Medical, St Paul, MN, USA) vascular plug device to occlude
the pseudoaneurysm. A 0.038-inch guidewire was advanced via the left common femoral
artery access and a 7-Fr sheath was inserted over the wire and advanced to the pseudoaneurysm
neck at the right common femoral artery. The Amplatzer 4 vascular plug was deployed
successfully [Figure 2]C. Post deployment, angiography demonstrated effective sealing of the right common
femoral artery at the level of the vessel wall [Figure 2]D. Repeat of Duplex ultrasound scan the next day demonstrated successful embolization
with no flow within the pseudoaneurysm [Figure 1]D. The patient did well with no immediate complications and was discharged home 24
h postprocedure.
Figure 2 (A-D): (A) Refractory pseudoaneurysm seen on angiography arising from the anterolateral
aspect of the right common femoral artery (white arrow); (B) Micropuncture needle seen engaged with the end of the straight wire at the
pseudoaneurysm neck (white arrow); (C) Amplatzer 4 vascular plugs deployed to occlude the pseudoaneurysm (white arrow); (D) Post deployment angiogram demonstrated successful closure of the pseudoaneurysm
Discussion
In this case, we describe the challenges faced in treating a refractory iatrogenic
femoral artery pseudoaneurysm using the technological armamentarium available to the
endovascular specialist. Thrombin injection is a widely accepted and effective technique
of treating pseudoaneurysms with experienced interventionalists.[3] However, it does come with significant risk of distal lower limb embolization with
serious outcomes.[4] The Angio-Seal vascular closure device started gaining popularity in 1994 and had
become a gamechanger in the closure of arteriotomy sites.[13] The learning curve in using the Angio-Seal to treat femoral artery pseudoaneurysms
can be easily overcome due to the familiarity of this vascular closure device with
most endovascular specialist. Robken et al.[10] concluded that the procedure would benefit a specific cohort of patients who have
large pseudoaneurysms often measuring >3 mm in size with a neck diameter et al.,[10] in which the major limitation of this procedure is that it is less likely to be
successful in pseudoaneurysms with necks or orifices measuring >5 mm, because of the
inability of the polymer anchor to sit in an orifice of this size. However, using
other devices available such as the Amplatzer vascular plug has proven to be a safe
and feasible alternative to sealing the pseudoaneurysm.
Conclusion
This report describes the successful endovascular treatment of an iatrogenic refractory
femoral artery pseudoaneurysm using an Amplatzer 4 vascular plug, following unsuccessful
retrograde deployment of an Angio-Seal vascular closure device via wire capture technique.
It is important for the endovascular specialist to identify the right cohort of patients
to treat using this novel technique and to consider all technological armamentarium
available when technical difficulties are encountered. Allen R, Pseudoaneurysm repair
using Amplatzer vascular plug [Videos 1-7].
