Temporary Aortic Occlusion to Facilitate Large-Bore Arterial Closure

ABSTRACT: Percutaneous closure of large-bore arterial sheaths remains a clinical challenge. We report a case of facilitated large-bore closure using a low-profile valvuloplasty balloon for aortic occlusion. This technique enhanced percutaneous closure device deployment and improved hemostasis during arteriotomy closure. J INVASIVE CARDIOL 2010;22:503–504 ——————————————————————————— The number of structural heart interventions that require large-bore arterial sheaths continues to increase. In order to perform these endovascular procedures in a completely percutaneous manner, delivery sheaths of up to 24 Fr need to be inserted into the ilio-femoral vasculature. If no direct arterial exposure is performed, these sheaths are typically inserted under a “preclosed” arterial access using a variety of different vascular closure devices. There are a wide variety of techniques and closure products employed to “preclose” the femoral artery. These devices then need to be successfully deployed after delivery sheath removal in order to gain hemostasis. Achieving hemostasis in these cases can be difficult and fraught with complications.^1,2 One hurdle to successful percutaneous closure is controlling the arteriotomy bleeding after the large-bore delivery sheath is removed and the closure devices are ultimately deployed. Lack of hemostasis while deploying the closure devices after removal of the sheath not only leads to blood loss, but hematoma formation, which hinders postoperative ambulation and results in patient discomfort. This report illustrates the novel use of a low-profile valvuloplasty balloon to facilitate closure-device deployment and achievement of hemostasis in a 24 Fr “preclosed” arteriotomy.

Case Description

A 93-year old male with critical aortic stenosis underwent transcatheter aortic valve intervention (TAVI). A 24 Fr delivery sheath was required for the procedure. The case was done in a completely percutaneous manner with no arterial cutdown performed. Percutaneous access and closure method. Initially, fluoroscopy of the left femoral head was performed to locate the ideal area for femoral artery puncture. An 18 gauge Cook needle (Cook Medical, Inc., Bloomington, Indiana) was used to enter the left common femoral artery. A 6 Fr sheath was placed in the artery via a modified Seldinger technique. A standard sheath introducer wire was inserted through the sheath and the sheath was removed over the wire. A total of 3 Perclose-AT closure devices (Abbott Laboratories, Abbott Park, Illinois) were deployed in a preclose fashion. The first, in a 10 to 4 o’clock orientation, the second in a 2 to 7 o’clock orientation and the third in a 12 to 6 o’clock orientation. An 8 Fr sheath was then advanced into the artery. A dose of 200 mcg of intra-arterial nitroglycerin and nicardipine were delivered through the sheath. The artery was then dilated sequentially with 10, 12, 14, 18, 22 and 24 Fr dilators. A 24 Fr sheath was then advanced into the artery over an extra-stiff Amplatz J-wire (AGA Medical, Golden Valley, Minnesota) to the level of the distal thoracic aorta. The contralateral femoral artery was punctured with an 18 gauge Cook needle and an 8 Fr sheath was introduced. A 6 Fr pigtail catheter was advanced through the 8 Fr sheath and placed in the ascending aorta. The transcatheter aortic valve intervention was successfully performed. The 24 Fr dilator was advanced back into the valve delivery sheath. Over the Amplatz J-wire the dilator and sheath were pulled back into the common iliac artery. The pigtail catheter was removed from the contralateral sheath over a 0.35" table wire. A Tyshak II 22 mm x 4 cm valvuloplasty balloon (B. Braun Medical, Inc., Bethlehem, Pennsylvania) was advanced through the 8 Fr sheath to the level of the distal abdominal aorta. The valvuloplasty balloon was inflated with 25 cc of contrast-dye admixture. The 24 Fr sheath was then removed over the Amplatz wire. There was complete hemostasis with no manual pressure required to control the arteriotomy site. The knots of the Perclose-AT closure devices were then advanced down to the arteriotomy without “locking” them. The valvuloplasty balloon was gradually deflated and assessment of hemostasis was performed. The Amplatz wire was removed and the valvuloplasty balloon was reinflated. The Perclose sutures were fully locked and the balloon was deflated. There was excellent hemostasis and no hematoma. The balloon and wire were removed from the contralateral arteriotomy. Total blood loss for the case was an estimated 50 cc.

Discussion

Completely percutaneous large-bore sheath closure remains a clinical dilemma. One challenging aspect of closing such large arteriotomies is maintaining hemostasis while the closure devices used to preclose the vessels are ultimately deployed. Aortic occlusion with large-diameter balloons to facilitate arterial control is well established.³ The use of a low-profile, large diameter valvuloplasty balloon for this purpose has not been previously described. The technique documented here serves a multitude of purposes. It facilitates large-bore sheath arterial closure by foregoing the need for manual hemostasis during deployment of the preclose devices. Manual hemostasis in the setting of a large-diameter arteriotomy can be physically challenging and distortion of the access site can lead to suboptimal device deployment. Lack of adequate hemostasis during preclose-device deployment may lead to increased blood loss, with the need for > 2 Units of blood in up to 24% of cases,⁴ hematoma formation and postoperative morbidity.¹ Temporary aortic occlusion to facilitate arterial closure is not a unique concept. However, the balloons used for this purpose as previously described require upwards of a 12 or 14 Fr contralateral sheath to be placed.⁵ This presents another arterial access of a large diameter that cannot be safely controlled with manual hemostasis if needed. The use of a low-profile, 8 Fr sheath-compatible valvuloplasty balloon for this purpose has not been previously described. This method proved to be safe and effective in facilitating closure of a 24 Fr arteriotomy in this patient. Potential complications with this technique of aortic occlusion are dissection and plaque disruption in the distal abdominal aorta. While we have not encountered any such complications, a randomized evaluation of this technique is warranted.

References

1. Kahlert P, Eggebrecht H, Erbel R, Sack S. A modified “preclosure” technique after percutaneous aortic valve replacement. Catheter Cardiovasc Interv 2008;72:877–884. 2. Bangalore S, Arora N, Resnic FS. Vascular closure device failure: Frequency and implications: A propensity matched analysis. Circ Cardiovasc Interv 2009;2:549–556. 3. Miura F, Takada T, Ochiai T, et al. Aortic occlusion balloon catheter technique is useful for uncontrollable massive intra-adbominal bleeding after hepato-pancreato-biliary surgery. J Gastrointest Surg 2006;10:519–522. 4. Yan TD, Cao C, Martens-Nielsen J, et al. Transcatheter aortic valve implantation for high-risk patients with severe aortic stenosis: A systematic review. J Thorac Cardiovasc Surg 2010;139:1519–1528. 5. Sharp ASP, Michev I, Maisano F, et al. A new technique for vascular access management in transcatheter aortic valve implantation. Catheter Cardiovasc Interv 2010;75:784–793.

——————————————————————————— From Medical City Dallas Hospital, Dallas, Texas and ^†Cardiopulmonary Research Science and Technology Institute, Dallas; and Erasmus University Medical Center, Rotterdam, The Netherlands. The authors report no conflicts of interest regarding the content herein. Manuscript submitted July 9, 2010, provisional acceptance given August 9, 2010, final version accepted August 27, 2010. Address for correspondence: Bruce S. Bowers, MD, Medical City Dallas Hospital, The Dallas Heart Group, Dallas, TX 75230-2522. E-mail: brucebow@baylorhealth.edu