Cath Lab Digest

ABSTRACT: A 91-year-old male with history of peripheral vascular disease and existing stent in the common femoral artery presented with contralateral critical limb ischemia. Our case demonstrates the successful closure of a femoral access site through a stent utilizing an active extravascular closure device.

VASCULAR DISEASE MANAGEMENT 2012:9(5):E68-E70

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Case Report

A 91-year-old male with history of peripheral arterial disease, coronary artery disease, hypertension, dyslipidemia, chronic kidney disease, and ischemic heart disease presented with critical limb ischemia and rest pain of the left lower extremity. He had previously undergone cutting balloon angioplasty and stenting of the right common femoral artery (CFA), as well as atherectomy, cryoplasty, and angioplasty of the right superficial femoral artery (SFA) into the popliteal artery for in-stent restenosis almost 1 year prior. He was admitted on this encounter for treatment of the left SFA.

Access was obtained through the existing stent in the right femoral artery using a micro-puncture access kit and upsized to a 7 Fr sheath (Figure 1).  After crossing the aortoiliac bifurcation into the left external iliac artery using a Rim catheter (Cordis Corporation), a 7 Fr Ansel sheath (Cook Medical) was advanced over an Amplatz stiff wire (Cook) into the left external iliac artery. Angioplasty was performed on the left SFA with good angiographic result and brisk flow into the left foot. 

Selective angiogram of the right CFA showed patent stents (Figure 2) with mild-to-moderate disease in the distal SFA and 2-vessel runoff into the right foot. A Mynx with Grip Technology (AccessClosure, Inc) vascular closure device (VCD) was deployed in the right CFA with adequate hemostasis and the patient discharged home the following day without complications.

The patient was seen in follow up 4 months later and findings from duplex arterial Doppler showed no stenosis within the access site in the right CFA (Figure 3).

Discussion

The increasing prevalence of peripheral arterial disease and treatment of the CFA and SFA with stents creates a challenge when repeat access is required. Although there is limited published literature on this clinical scenario, some risks may be assumed during hemostasis of such access sites. Manual compression may result in crushing of the stent, and VCDs may disrupt the integrity of the existing stent. VCDs with intra-arterial components may disturb the flow dynamics within the stent, increasing the likelihood of restenosis.^1-9 Those with extravascular clips may fail to capture sufficient tissue at the arteriotomy in a vessel stiffened by an existing stent and suture-based VCDs may likewise be unable to adequately penetrate the stented access site. However, VCDs, if successfully deployed, present a desirable alternative as they reduce time to hemostasis and ambulation as well as improve patient comfort.^10-26 Therefore, an extravascular VCD with minimal impact on the vessel and stent integrity would offer the best possibility of a positive outcome.^27,28

The Mynx with Grip Technology VCD is an extravascular, bioabsorbable system (Figure 4) that utilizes a polyethylene glycol (PEG) hydrogel sealant in 2 different formulations. The formulation of the proximal segment contains PEG components that have been reacted, cross-linked, and freeze-dried, creating a porous structure.²⁹ The porous structure absorbs blood and subcutaneous fluids, expanding 3-4 times its original size and filling the tissue tract. In the distal segment, the PEG components are combined, but are not reacted or cross-linked, triggering them to react and cross-link when exposed to the Ph level and temperature inside the body.  This cross-linking causes the PEG to soften and interlock with the contours of the vessel wall. Hemostasis is achieved through the combination of sealant expansion and active adherence to the artery wall. Early studies evaluating the Mynx VCD confirmed the hemostatic safety and efficacy of the device in diagnostic and interventional catheterization procedures.²³ A prospective randomized trial of patient comfort following closure with the Mynx VCD revealed less pain than with other intravascular anchoring VCDs.²⁴

Our case demonstrates a unique application of the active extravascular VCD in the successful closure of a rare femoral access site through an existing stent.