BACKGROUND:
Complications of the vascular access-site (VAS) are not uncommon. With the evolution of hemostatic techniques used in the access site closure, in the last two decades, the rate of VAS related complications has significantly reduced from 6% to 2%. However, they still remain to be an important cause of morbidity following catheterization procedures. The most common complications encountered with closure of VAS are hematoma formation, arterio-venous fistula, dissection, pseudo -aneurysm and limb ischemia. According to two meta-analyses, the incidences of these complications were very low. The incidence of collagen plug from an Angioseal(™) device causing acute leg ischemia is low and upon occurrence, the use of an Angioscore(™) balloon in successful revascularization has never been reported.
CASE PRESENTATION:
A 62-year-old male with known severe peripheral artery disease, diabetes mellitus, hypertension and hypercholesterolemia had a successful angioplasty of a 100% chronically occluded right superficial femoral artery (SFA) via the left common femoral artery. An Angioseal (™) closure device was used to achieve hemostasis. The patient was discharged home after an uneventful post procedural course. Two days later, he presented to the ER with a cold and numb left lower extremity. On exam, the left lower extremity had no palpable pulse from below right femoral artery, confirmed by Doppler. The extremity was cold to touch with decreased sensory perception. Patient was found to have critical left lower extremity ischemia. He was emergently taken for a selective left lower extremity angiogram using the right common femoral artery for access. Fragments of the closure device and a collagen plug causing a total occlusion of the left common femoral artery were found. After a pre-dilatation with a 4.0x 40 balloon under prolonged inflations, a lesion reduction from 100 % to 30% with a TIMI 0 to TIMI 3 flow was achieved using an Angioscore (™) 5.0x 40 balloon inflated at 10 atmospheres. Subsequently, using laser 2.0 atherectomy of the left common femoral artery was performed. Flow in the dorsalis pedis artery was confirmed with Doppler.
DISCUSSION:
The Angio-Seal(™) device has a polylactide and polyglycolide polymer anchor, a collagen plug and a suture contained within a carrier system. Hemostasis is achieved by compressing the arterial puncture site between the anchor and the collagen plug. With newer studies, it appears that the occurrence of critical limb ischemia from collagen plug is under recognized. We therefore, with this case report urge the physicians to be aware of this serious though rare complication of closure devise and also highlight the successful use of Angioscore (™) balloon in the emergent treatment of non-athermatous vascular occlusion causing critical limb ischemia.
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