Novel Strategy for Percutaneous Access Closure in Patients With Zero Tolerance for Bleeding

Complications related to arterial access continue to plague the interventionalist, despite advances in vessel closure technology. The incidence of complications appears to be related to sheath size as well as the size and condition of the native vessel. The reported frequency for complications of percutaneous transcatheter aortic valve implantation (TAVI), which necessitates insertion of large-bore intravascular devices through large sheaths, ranges from 1.9% to 30.7%.¹ According to the Valve Academic Research Consortium 2 (VARC-2) criteria, major vascular complications are reported in 3 to 15% of cases.² Lower rates have been reported in registries.^3-6

If the access vessel is diseased with circumferential calcification or marginal in size in comparison to the sheath size, surgical cut down is the preferred option. In urgent cases, where there may be no opportunity to preclose the common femoral artery before placing an extracorporeal membrane oxygenation (ECMO) cannula in a patient in extremis, decannulation with closure of the access vessel can be a serious challenge. It is in these situations in particular that any complications related to bleeding, pseudoaneurysm, dissection, or thrombosis could lead to increased morbidity and mortality. This observation is supported by a mortality rate of up to 50% reported in all patients requiring ECMO.⁷

Case Report 1

We describe the case of a 74-year-old male who suffered cardiac arrest while undergoing left heart catheterization for evaluation of chest pain. He had undergone prior percutaneous coronary intervention (PCI) for coronary artery disease. Venoarterial (VA)-ECMO for circulatory support was required for an extended period of time. ECMO cannulas had been placed via the right common femoral artery and vein. A decision was made to switch from ECMO to an Impella device (Abiomed) to avoid complications related to a groin wound and risk of sepsis. The patient remained in critical condition, whereby any adverse event would be poorly tolerated, resulting in a likely mortality.

We decided to place a covered stent in the right common femoral artery while removing the ECMO cannula to avoid bleeding or any vascular complication. Ultrasound-guided cannulation of the left common femoral artery was performed and after access of the right common iliac artery was achieved, a .035-inch Glidewire Advantage (Terumo) was advanced over the aortic bifurcation into the proximal right superficial femoral artery and an 11 French (Fr) curved sheath (Cook Endovascular) was advanced over the wire to the level of the right external iliac artery. A 9 mm x 59 mm balloon-expandable iCAST stent (Atrium Medical) was positioned precisely, with the midpoint of the stent at the point of entry of the cannula in the native vessel. As the cannula was withdrawn, the stent was expanded, with immediate hemostasis achieved. Figure 1 shows stent placement and flow through the vessel without evidence of extravasation. The left femoral access had been preclosed with two 6 Fr Perclose ProGlide sutures (Abbott Vascular), allowing closure without problems. The Impella device had been placed and the patient was weaned from ECMO.

Case Report 2

The second case is that of a 74-year-old female undergoing secondary thoracic endovascular aneurysm repair (TEVAR) for a 6 cm aneurysm involving zone 4 and 5 of the descending thoracic aorta. Owing to the extreme tortousity of the involved segment of the aorta, a 14 Fr Edwards sheath (Edwards Lifesciences) had to be introduced from the left femoral artery without the opportunity to preclose the vessel. The patient had undergone prior cut down of this artery with wound breakdown and healing of the groin incision by secondary intent over a period of 3 months. We wished to avoid having to do a cut down over this vessel, if at all possible. Additionally, on angiography, dissection of the left external iliac artery was noted, presumably from sheath injury. Individual 9 mm x 59 mm and 9 mm x 39 mm iCAST stents were delivered through a 7 Fr crossover sheath to cover the external iliac artery and common femoral artery, with complete hemostasis achieved. Figure 2 demonstrates the stent placement and flow through the left femoral artery. 

Discussion

The technique of “up and over” control of the reference femoral artery while dealing with a difficult access is well described in the literature. Operators have used balloon occlusion of the common femoral artery and/or the external iliac artery for tamponade as a bridge to surgical repair or primary repair using closure devices or covered stents.^8-11 A 9 mm iCAST stent can be delivered through a 7 Fr sheath and dialed up, if necessary, with a bigger balloon.

The first case described above is unique in that the technique of endovascular repair of the common femoral artery is the first reported case following removal of an ECMO cannula, to the best of our knowledge. The stakes are so high that any complication in this setting would likely result in mortality or major morbidity. The second case represents a not-too-uncommon scenario when one is confronted with unexpected problems during the performance of a complex TEVAR. Surgical cut down to repair the femoral artery would have been another option, attendant with increased morbidity. The technique presented above should be part of the armamentarium of the interventionalist dealing with life-threatening emergencies in increasingly compromised patients.

References

1. Vavuranakis M, Kalogeras KI, Vrachatis DA, et al. A modified technique to safely close the arterial puncture site after TAVI. J Invasiv Cardiol. 2013; 25: 259-274.
2. Kappetein AP, Head SJ, Genereux P, Piazza N, van Mieghem NM, Blackstone EH, et al. Updated standardized endpoint definitions for transcatheter aortic valve implantation: the Valve Academic Research Consortium-2 consensus document. Eur Heart J. 2012; 33: 2403-2418.
3. Thomas M, Schymik G, Walther T, Himbert D, Lefevre T, Treede H, et al. Thirty-day results of the SAPIEN Aortic Bioprosthesis Eurpean Ouctome (SOURCE) Registry: a European registry of transcatheter aortic valve implantation using the Edwards SAPIEN valve. Circulation. 2010; 122: 62-69.
4. Genereux P, Webb JG, Svensson LG, Kodali SK, Satler LF, Fearon WF, et al; PARTNER Trial Investigators. Vascular complications after transcatheter aortic valve replacement: insights from the PARTNER (Placement of AoRTic TraNscathetER Valve) trial. J Am Coll Cardiol. 2012; 60: 1042-1052.
5. Genereux P, Head SJ, Van Mieghem NM, Kodali S, Kirtane AJ, Xu K, et al. Clinical outcomes after transcatheter aortic valve replacement using Valve Academic Research Consortium definitions: a weighted meta-analysisof 3,519 patients from 16 studies. J Am Coll Cardiol. 2012: 59: 2317-2326.
6. Van Mieghem NM, Tehetche D, Chieffo A, Dumonteil N, Messika-Zeitoun D, van der Boon RM, et al. Incidence, predictors, and implications of access site complications with transfemoral transcatheter aortic valve implantation. Am J Cardiol. 2012;110:1361-1367.
7. Zangrillo A, Landoni G, Biondi-Zoccai G, Greco M, Greco T, Frati G, et al. A meta-analysis of complications and mortality of extracorporeal membrane oxygenation. Crit Care Resusc. 2013 Sep; 15(3): 172-178.
8. Genereux P, Kodali S, Leon MB, et al. Clinical outcomes using a new crossover balloon occlusion technique for percutaneous closure after transfemoral aortic valve implantation. JACC Cardiovasc Inter. 2001; 4: 861-867.
9. Buchanan GL, Chieffo A, Montorfano M, et al. A “modified crossover technique” for vascular access management in high-risk patients undergoing transfemoral transcatheter aortic valve implantation. Catheter Cardiovasc Interv. 2013; 81: 579-583.
10. Curran H, Chieffo A, Buchanan GL, et al. A comparison of the femoral and radial crossover techniques for vascular access management in transcatheter aortic valve implantation: the Milan experience. Catheter Cardiovasc Interv. 2014; 83: 156-161.
11. Garci E, Martin-Hernandez P, Unzue L, Hernandez-Antolin RA, Almeria C, Cuadrado A. Usefulness of placing a wire from the contralateral femoral artery to improve the percutaneous treatment of vascular complications in TAVI. Rev Esp Cardiol (Engl Ed). 2014; 67: 410-412. 

Disclosures: The authors report no conflicts of interest regarding the content herein. 

The authors can be contacted via Therese Federowicz, MD, at therese.federowicz@inova.org.