Vascular complications arising during or after percutaneous access of the femoral artery have decreased over the past decade, but still present a problem in some cases. The use of vascular closure devices for femoral artery access management has allowed early ambulation and improved patient satisfaction with a safety profile that is equivalent, or in some circumstances better, than is observed with manual compression. Striving to achieve complication-free vascular access is a goal of all practicing physicians. The sharing of information relevant to better access techniques and uncommon complications is part of this process.
I read with interest the case report of Sharegi and Shavelle, detailing acute femoral artery occlusion complicating a diagnostic cardiac catheterization procedure. The case involved a young woman with an apparent dilated cardiomyopathy, but abnormal stress echocardiogram, referred for cardiac catheterization. The femoral artery stick location in the common femoral artery was confirmed by a femoral arteriogram, which also demonstrated normal appearance of the vessel. The catheterization procedure, and subsequent access site closure using a 6-Fr Angio-Seal STS Plus device were performed without apparent complication. At 1-hour post-procedure, the patient developed symptomatic occlusion of the femoral artery. A subsequent femoral artery angiogram, using access from the contralateral femoral artery, revealed a filling defect in the right common femoral artery, proximal to the original access site. Local attempts at thrombolysis failed to restore patency, and operative repair of the vessel was required. At the time of exploration, a large dissection flap was noted, but was not contiguous with the original access site, or presumably the Angio-Seal anchor. The vessel was repaired and flow was restored without apparent further sequelae.
The authors should be applauded for providing details of this potentially serious complication. Sharing the information relevant to this case is one of the ways we can all benefit in helping to reduce vascular complications after femoral artery access. The use of a femoral arteriogram prior to placing a closure device, as was done in this case, is one of several steps necessary to ensure optimal use of closure devices. The authors focus on the possibility that the Angio-Seal anchor was responsible for the complication. However, I believe that there are other potential mechanisms that are equally or more likely to be responsible for the complication. Collagen-based devices, including the Angio-Seal device, have been reported to cause local vascular complications including vessel occlusion. The common denominator in these cases appears to be intra-arterial deployment of the device, and/or the presence of vascular disease at the access site. Almost all of the vascular sequelae from these device-related complications involve flow obstruction distal to the device. In this case, a filling defect, presumably the dissection, was noted proximal to the access site and the Angio-Seal anchor. Intimal disruption proximal to the access site can occur from needle injury, wire trauma or sheath disruption of the vessel, and importantly, is not apparent until the sheath is removed. The lack of involvement of the access site in the flap, and the proximal location of the filling defect noted on angiography, argue that this was not likely a complication arising from deployment of the Angio-Seal anchor. Also, it would be useful to know if this patient had pathology of the arterial wall, such as cystic medical necrosis, which may have predisposed her to this complication. Whatever is the real mechanism of this complication, it is important that we continue to share details of vascular complications to better understand and improve femoral artery access management. |
