Serial angioscopy during treatments for ProGlide-related femoral occlusion following transcatheter aortic valve implantation

Open ArchivePublished:October 18, 2020DOI:https://doi.org/10.1016/j.jccase.2020.09.006

      Abstract

      Vascular complications associated with vascular closure device use is uncommon; however, it sometimes occurs in transfemoral transcatheter aortic valve implantation (TF-TAVI). We present a case of ProGlide (Abbott Vascular, Santa Clara, CA, USA)-related right femoral occlusion following TF-TAVI. An 83-year-old woman, who underwent TF-TAVI using double ProGlide pre-closure technique, presented with right claudication three days after TAVI. Computed tomography showed femoral occlusion of the puncture site. Recanalization without pressure gradient between the proximal and distal sites of the lesion was achieved by balloon angioplasty (BA) with a 4.0 mm balloon; however, early re-occlusion of the lesion occurred the next day after BA. Repeated BA was performed for the re-occlusion site 30 days after TAVI because of persistent claudication. Serial angioscopic images of the lesion revealed that the intima, which was injured at the first BA, had healed at the second BA, indicating that BA with larger balloons could be safely performed. We performed BA with a 6.0-mm balloon without stent implantation. The patency of the lesion was maintained during the 6-month follow-up period. The serial angioscopic findings, which revealed the healing process of the intima injury, were useful in determining a suitable endovascular therapy strategy for ProGlide-related occlusion.
      <Learning objective: ProGlide-related femoral occlusion can occur in arteries without stenosis, calcification, and vessel branching, suggesting that ProGlide should be carefully used with echo-guidance to avoid the occlusion of a puncture site. If endovascular therapy is performed for the lesion to avoid surgical repair, sufficient expansion is required to maintain patency. Angioscopy may be useful for determining a suitable endovascular therapy strategy for the lesion by evaluating the properties of the intima.>

      Keywords

      Introduction

      Percutaneous transfemoral (TF) approach using vascular closure devices (VCDs) is one of the most favorable strategies in transcatheter aortic valve implantation (TAVI) [
      • Pineda A.M.
      • Rymer J.
      • Wang A.
      • Koweek L.H.
      • Williams A.
      • Kiefer T.
      • et al.
      Trends and outcomes of alternative-access transcatheter aortic valve replacement.
      ,
      • Kawashima H.
      • Watanabe Y.
      • Kozuma K.
      • Nara Y.
      • Hioki H.
      • Kataoka A.
      • et al.
      Propensity-matched comparison of percutaneous and surgical cut-down approaches in transfemoral transcatheter aortic valve implantation using a balloon-expandable valve.
      ]. However, VCD-related vascular complications, such as stenosis, occlusion, bleeding, hematoma, and the formation of a pseudoaneurysm, sometimes occur [
      • Barbash I.M.
      • Barbanti M.
      • Webb J.
      • Molina-Martin De Nicolas J.
      • Abramowitz Y.
      • Latib A.
      • et al.
      Comparison of vascular closure devices for access site closure after transfemoral aortic valve implantation.
      ]. For these complications, especially stenosis or occlusion, endovascular therapy (EVT) is considered one of the viable options; however, the strategy of EVT has not been established. We report a case of a ProGlide (Abbott Vascular, Santa Clara, CA, USA)-related femoral occlusion treated with balloon angioplasty under angioscopy guidance.

      Case report

      An 83-year-old woman with severe aortic stenosis underwent TF-TAVI using a 14 Fr e-sheath (Edwards Lifesciences, Irvine, CA, USA) via the right femoral artery (FA). Pre-procedural computed tomography (CT) showed no extensive calcification in the ilio-femoral artery, and the minimum diameter of the right FA was 6.3 mm (Fig. 1A). Hemostasis of the puncture site was immediately achieved; however, the patient presented with right claudication three days after TAVI. The patient’s right ankle-brachial index (ABI) had reduced from 1.05 before TAVI to 0.55 after TAVI.
      Fig. 1
      Fig. 1Pre- and post-transcatheter aortic valve implantation (TAVI) computed tomography (CT) images and fluoroscopy, intravascular ultrasound, and angioscopy findings during the first endovascular therapy. (A) Pre-TAVI CT showing no stenosis and calcification in the right ilio-femoral artery. No vessel branches are observed near the puncture site. (B) Post-TAVI CT showing a focal occlusion (red arrowhead) of the right femoral artery (FA). (C) Fluoroscopy showing focal occlusion of the right FA. Intravascular ultrasound indicating intimal peeling at the occlusion site (yellow arrowheads). (D) Angioscopy demonstrating the captured intima of the posterior wall close to the anterior wall accompanied by intimal injury. (E) A schema illustrating the mechanism of occlusion of the femoral artery. ProGlide interferes with the intima of the posterior wall, leading to the femoral artery occlusion. (F) Fluoroscopy immediately after the first endovascular therapy.
      Post-procedural CT and fluoroscopy, which was performed four days after TAVI, revealed focal occlusion of the right FA (Fig. 1B and C). Intravascular ultrasound (IVUS) indicated intimal peeling at the occlusion site (Fig. 1C). Angioscopy demonstrated the captured intima of the posterior wall close to the anterior wall accompanied by intimal injury at the occlusion site (Fig. 1D, Supplementary Video S1). The “foot” of the ProGlide interfered with the intima of the posterior wall, and the ProGlide was used without modification, which resulted in the FA occlusion (Fig. 1E). Recanalization of the right FA was achieved with balloon angioplasty (BA) using a 4.0-mm balloon. No pressure gradient was observed between the proximal and distal sites of the lesion. In the early period after TAVI, no additional BA with a larger balloon was performed to avoid bleeding complications at the lesion, although moderate stenosis was noted on fluoroscopy (Fig. 1F). This is because angioscopic findings revealed an acute inflammation phase of the intima, which can easily cause bleeding complications by larger BA. However, the patient presented with right claudication again the day after BA. Repeated EVT was performed 30 days after TAVI because of the persistence of the patient’s claudication during the three-week follow-up. Fluoroscopy showed the re-occlusion of the puncture site (Fig. 2A). IVUS showed intimal peeling at the occlusion site (Fig. 2A). As noted earlier, angioscopy showed that the intima of the posterior wall was pulled close to the anterior wall at the occlusion site. However, the intima of the occlusion site had clearly healed (Fig. 2B, Supplementary Video S2), indicating that BA with larger balloons could be performed. Thus, we performed BA with a 6.0-mm balloon. After 20 min since the 6.0 mm balloon dilation, no lesion recoil was observed on fluoroscopy, IVUS, and angioscopy (Fig. 3, Supplementary Video S3). EVT was completed without stent implantation because the lesion was a non-stenting area. The patient’s right claudication improved, and the patient’s right ABI increased from 0.55 before to 0.77 after the repeated BA. At the 6-month follow-up, no claudication was noted, and the patient’s right ABI was 0.84.
      Fig. 2
      Fig. 2Fluoroscopy, intravascular ultrasound, and angioscopy findings before the second endovascular therapy. (A) Fluoroscopy before the second endovascular therapy. Intravascular ultrasound indicating intimal peeling at the occlusion site. (B) Angioscopy demonstrating the captured intima of the posterior wall close to the anterior wall with healed intima.
      Fig. 3
      Fig. 3Fluoroscopy, intravascular ultrasound, and angioscopy findings after the second endovascular therapy. (A) Fluoroscopy showing sufficient expansion at the occlusion site (white dotted line) after balloon angioplasty. (B) Intravascular ultrasound and (C) angioscopy showing sufficient lumen area at the occlusion site.

      Discussion

      The reported incidence of ProGlide-related vascular complications is 5% [
      • Barbash I.M.
      • Barbanti M.
      • Webb J.
      • Molina-Martin De Nicolas J.
      • Abramowitz Y.
      • Latib A.
      • et al.
      Comparison of vascular closure devices for access site closure after transfemoral aortic valve implantation.
      ]. History of peripheral artery disease, presence of common FA calcifications, depth of the skin puncture site >33 mm, body mass index >28.7 kg/m2, and vessel branching are reported as risk factors for ProGlide failure [
      • Archie M.
      • Farley S.
      Possible mechanism for common femoral artery occlusion with the perclose suture device.
      ]. In this case, femoral occlusion occurred in the absence of these recognized risk factors, suggesting the need to carefully use ProGlide to avoid device-related complications, such as stenosis or occlusion of a puncture site. An echo-guided technique, confirming ProGlide without interference with the posterior wall at the puncture site before depressing the needle plunger of the ProGlide, might be useful to prevent such complications [
      • Honda Y.
      • Araki M.
      • Yamawaki M.
      • Tokuda T.
      • Tsutumi M.
      • Mori S.
      • et al.
      The novel echo-guided ProGlide technique during percutaneous transfemoral transcatheter aortic valve implantation.
      ].
      Surgical repair is considered one of the optimal approaches for ProGlide-related occlusion [
      • Archie M.
      • Farley S.
      Possible mechanism for common femoral artery occlusion with the perclose suture device.
      ]; however, EVT was employed for the occlusion because of the patient’s refusal to undergo surgical repair in this case. The serial angioscopic findings, which revealed the healing process of the intima injury, were useful in deciding a suitable EVT strategy for ProGlide-related occlusion. Considering the mechanism of the occlusion (suture firing into the intima of the posterior wall), stent implantation would have been necessary for achieving the patency of the lesion. However, the common FA is considered a “non-stenting area” because of a possible stent fracture. According to our angioscopic findings of the intima healing process during 30 days after the occlusion, we could complete the EVT for the ProGlide-related occlusion site without stent implantation.
      In conclusion, ProGlide-related femoral occlusion can occur in arteries without stenosis, calcification, and vessel branching. In avoiding stent implantation to the lesion, angioscopic images may be useful in finding a suitable strategy of EVT for the lesion.

      Conflict of interest

      The authors declare that there is no conflict of interest.

      Declaration of Competing Interest

      The authors report no declarations of interest.

      Acknowledgments

      None.

      Appendix A. Supplementary data

      The following are Supplementary data to this article:

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