Challenging Case

Closure Device Complication

By HUGO A. QUINTANA, MD, AND TYRONE C. COLLINS, MD
 

CASE PRESENTATION
A 60 year-old Caucasian male with a history of hypertension, hyperlipidemia, previous CABG, and symptom-limiting angina underwent PTCA and stenting of the proximal LAD and LCX one week prior to presenting at my office. At the time of the interventional treatment, his physician obtained hemostasis of the right common femoral artery access site with a 6F Perclose device (Abbott Laboratories, Abbott Park, IL).

The patient complained of claudication of the right lower extremity that he noticed two days postprocedurally. Upon examination, I found that his common femoral pulse was not palpable and the popliteal was heard only with Doppler exam. The patient had an ABI of 0.3 on the right.

ANGIOGRAPHIC FINDINGS
I decided to perform a selective right common femoral angiography. The test revealed a subtotal occlusion of the right common femoral artery at the deployment site of the Perclose suture (Figure 1). The SFA and profunda femoris were patent and there was three-vessel run-off below the knee.

HOW WOULD YOU PROCEED?
1. Would you treat with the AngioJet rheolytic thrombectomy system (Possis Medical, Inc., Minneapolis, MN)?
2. Is catheter-directed thrombolysis an option?
3. Would PTA with provisional stenting offer a solution?
4. If stenting directly, would you use a balloon-expandable stent, a self-expanding stent, or a covered stent?

COURSE OF ACTION
I exchanged the diagnostic sheath for a 6F Crossover sheath (Cook, Bloomington, IN), which was advanced to the external iliac artery. I crossed the lesion with a 300-cm, 0.014 Sport guidewire (Guidant, Santa Clara, CA). Predilatation was performed with a 4 X 20-mm Talon balloon (Boston Scientific Corporation, Natick, MA). Due to a suboptimal angioplasty result, I deployed an 8 X 29-mm self-expanding Wallstent (Boston Scientific Corporation) (Figure 2) and performed postdilatation using a 6 X 12-mm Talon balloon.

OUTCOME
The patient began ambulating with complete resolution of claudication at 6 hours postprocedure. Upon examination, I detected brisk femoral, popliteal, and Dorsalis pedis pulses and found an ABI of 0.94. The patient went home the next day and has remained asymptomatic.
In the past, I would have been required to send this patient for surgical revascularization. Instead, advances in current technology and endovascular techniques allowed me to treat this limb-threatening complication efficiently and with low morbidity.

Hugo A. Quintana, MD, is an Interventional Cardiology Fellow in the Department of Cardiology at the Ochsner Clinic Foundation in New Orleans. Dr. Quintana may be reached at (504) 842-3786; hquintana@ochsner.org.

Tyrone J. Collins, MD, FACC, is Associate Section Head of Interventional Cardiology and Codirector of the Cardiac Catheterization Laboratory in the Department of Cardiology at the Ochsner Clinic Foundation in New Orleans. Dr. Collins may be reached at (504) 842-3786; tcollins@ochsner.org.

 

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