Ultrasonography-guided endovascular management of femoral artery pseudoaneurysm after unintended dialysis catheterization with suture-mediated vascular closure devices

Abstract

Although iatrogenic pseudoaneurysm is an infrequent complication, it can be life threatening if ruptured. There are several treatment methods for managing this complication. This case report demonstrates a technique using ultrasonography-guided suture-mediated vascular closure devices without angiography to successfully treat iatrogenic superficial femoral pseudoaneurysm following an unintended hemodialysis catheter insertion. In particular, when it is difficult to use a contrast due to a patient’s condition as in this case, suture-mediated vascular closure device with ultrasonography guidance can be used as a therapeutic method.

Introduction

Femoral pseudoaneurysm (PSA) can be caused by a perforation in the wall of artery with blood continuously flowing into the perivascular tissue to form a sac that is surrounded by adventitia or soft tissue. ¹ Although the prevalence of PSA varies among studies, its range is 0.2%–0.8% depending on the type of procedure. ² In the case of small PSA, observation is also a treatment method. However, if it ruptures, it might be life threatening. Thus, active treatment is required. ³ Ultrasonography-guided manual/probe compression or percutaneous thrombin injection to the PSA sac is commonly used to resolve PSA. ⁴ However, in some cases, these treatment options are ineffective or unsuccessful. The present report discusses a technique using ultrasonography-guided suture-mediated vascular closure devices without angiography to successfully treat iatrogenic superficial femoral pseudoaneurysm following an unintended hemodialysis catheter insertion to the superficial femoral artery. The present report was approved by the Ethics Committee of Eunpyeong St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea (IRB number: PC22ZASI0165).

Case description

A 64-year-old woman was referred for endovascular management for left superficial femoral artery PSA associated with an unintended intraarterial dialysis catheterization 1 week ago. She was subsequently diagnosed with unresectable renal cell carcinoma and multiple lung metastases. Pneumonia occurred after receiving chemotherapy, leading to septic shock and anuria status. Thus, continuous renal replacement therapy was planned for treating the anuria and a hemodialysis (HD) catheter was inserted.

During bedside insertion of a HD catheter into the left femoral vein without ultrasonography, a superficial femoral artery was incorrectly punctured and then a 12 Fr dilator was inserted, followed by close observation for about 1 week after compression. Afterward, the palpable mass at the puncture site did not show any improvement. Therefore, a consultation for management of this problem was requested. The first ultrasonography-guided compression was performed. However, there was no improvement even after about 30 min. Although surgery could be considered as the next option, endovascular access was decided as it was judged that it was difficult to proceed with surgery due to the patient’s general condition including pneumonia.

On Doppler ultrasonography, a focal wall defect of about 3 mm and an aneurysmal neck were observed in the proximal superficial femoral artery with several sacs connected, all showing a high flow yin-yang sign. Fortunately, there were no findings suggestive of an arteriovenous fistula on the femoral vein (Figure 1).

Figure 1.

A neck between the focal wall defect of superficial femoral artery and the pseudoaneurysm is observed on ultrasonography. Through this neck, ultrasonography-guided puncture was performed with a 21G needle. It then entered into the femoral artery lumen.

After making a 3 mm incision in the skin under local anesthesia, direct puncture of the aneurysmal neck was performed percutaneously under ultrasonography guidance using a 21G microneedle. A microwire was inserted. A 5 Fr micro introducer was then introduced through the microwire. After inserting a 0.035-inch hydrophilic guidewire, it was confirmed that the retrograde approach to the iliac artery was successful through ultrasonography guidance (Figure 2). Closure was performed using a suture-mediated vascular closure device (Perclose Proglide; Abbott Vascular Devices, Redwood city, CA, USA). At this time, three closure devices were used in different directions (10, 12, and 2 o’clock), similar to the Pre-close technique used for procedures that required a large bore device insertion (Figure 3).

Figure 2.

After a suture-mediated vascular closure device (Perclose Proglide) was introduced along the 0.035-inch guidewire, the foot of the device was unfolded and retraction was done to the vessel wall defect. Ultrasonography confirmed that the foot plate was in the proper position.

Figure 3.

Insertion of the guidewire through the vascular closure device again and preparation of the next device. At this time, it was confirmed that the vessel wall defect was partially closed.

Immediately after the procedure, on Doppler ultrasonography, the high flow yin-yang sign of the PSA sac disappeared and hyperechoic thrombus formation was confirmed inside. After confirming that the focal wall defect was also obliterated, the procedure was completed (Figures 4 and 5).

Figure 4.

After applying a total of three vascular closure devices, the abnormal flow to the wall defect was no longer observed in Doppler ultrasonography.

Figure 5.

Immediately after the procedure, it was confirmed that the flow was stagnated in the multiple pseudoaneurysm sac and the yin-yang sign disappeared on Doppler ultrasonography.

Discussion

In the treatment of an iatrogenic pseudoaneurysm, both safety and effectiveness of the treatment method must be considered. As mentioned earlier, ultrasonography-guided manual compression was performed first. However, results were disappointing. The second consideration was direct percutaneous thrombin injection. According to several studies, it has a success rate of over 90%. Its effect is good even when the neck width is close to 5.0 mm and the lesion size reaches 40 mm.^1,4,5 However, considering that complications of this method are embolization and allergic reaction, if multiple PSAs develop over time as in this case, it is difficult to choose this method because the amount of thrombin injection is increased and the blood flow in the aneurysm is irregular.

The third method is to use a suture-mediated vascular closure device by direct puncture of the PSA. Usually the location of the lesion is identified through angiography using a contrast and the result of the procedure is confirmed.^6,7 However, in this case, there was a limitation in the use of contrast due to the patient’s severely decreased renal function. Nevertheless, it is important that the location of the lesion, PSA neck evaluation, and the confirmation of the postoperative result can all be sufficiently performed under ultrasonography guidance. As can be seen in the previous papers that used angiography, the existing method visualized the femoral artery and PSA neck to pass the guidewire through the PSA neck after direct puncturing the PSA, and used it as a landmark.^8,9 Therefore, the main limitation when only ultrasonography is used without angiography as in this study is that it is difficult to insert the guidewire into the femoral artery lumen thorough the PSA neck without any landmark after puncturing the PSA sac. As in our report, in order to perform with only the ultrasonography-guided technique, after puncturing the PSA sac, fix the direction of the puncture needle toward the PSA neck and advance the guidewire or it may be necessary to advance the needle through the pseudoaneurysm neck to the inside of the wall defect. If the guidewire enters the femoral artery lumen through this process, the result can be easily confirmed by ultrasonography (Figure 6(a)).

Figure 6.

Illustrations demonstrate a technique using ultrasonography-guided (a) micropuncture access and (b) suture-mediated vascular closure devices without angiography to treat superficial femoral pseudoaneurysm.

CFA: common femoral artery; DFA: deep femoral artery; SFA: superficial femoral artery; PSA: pseudoaneurysm.

In addition, this method is meaningful in that even if the neck of PSA is relatively wide, it is possible to sufficiently treat it using multiple closure devices. In this case, a wall defect caused by a device with an outer diameter of 12 Fr was closed using suture-mediated vascular closure devices. According to instructions for use (IFU), when using Pre-close technique, it can be used for arterial sheath puncture site closure with and outer diameter of 8 Fr up to 26 Fr. On the other hand, in the general case where the Pre-close technique is not used, the guideline suggest that it can be used up to an outer diameter of 8 Fr.

The Perclose device is structurally 20.7 Fr in distance between the two needles in which the vascular suture is performed (Figure 6(b)). That is, theoretically, in the case of a wall defect with a diameter of about 20 Fr, suture is possible using a Perclose device as suggested in this report. However, in the case of a wall defect exceeding 8 Fr, the limit suggested by the IFU, if only single device is used, the lateral side of the suture site may not be properly sutured and remain as a defect (so called dog-ear). Therefore, in this case, as in this report, it will be necessary to use multiple suture-mediated vascular closure devices in various directions.

Most iatrogenic arterial injuries due to bedside catheterization occur in the superficial femoral artery rather than the common femoral artery due to the nature of the procedure. When using a closure device, caution is required because stenosis, bleeding, and dissection occur frequently during treatment.^10,11 In this case as well, it is absolutely necessary to check whether the foot of device is not caught in the femoral bifurcation or the mural thrombus in the process of using three vascular closure devices. By using real-time ultrasonography, it was found that safe and accurate procedure could be performed (Figures 2 and 6(b)). ¹²

Conclusions

In this case, focal wall defects and multiple PSA in the superficial femoral artery caused by unintended catheterization were successfully treated with suture-mediated vascular closure devices using ultrasonography guidance. In particular, when it is difficult to use a contrast due to the patient’s condition as in this case or the use of other method is difficult due to a large defect, vascular closure device with ultrasonography guidance can be used as an effective therapeutic method.