Novel interventional technique for the treatment of an iatrogenic pseudoaneurysm of the brachial artery

Highlights

• •To understand the potential risk and management of pseudoaneurysm which is associated with percutaneous catheterization.
• •To understand the treatment options for pseudoaneurysm with endovascular method.
• •To understand the technical tips about intervention to pseudoaneurysm.

Abstract

This report presents the successful repair of an iatrogenic brachial artery pseudoaneurysm in a 72-year-old man who had peripheral artery disease and received endovascular treatment. A novel interventional method for treating iatrogenic femoral pseudoaneurysms with Perclose Proglide (Abbott Vascular Devices, Redwood City, CA, USA) has been reported; however, since a direct sheath insertion into the lumen of the pseudoaneurysm is initially required at the first step of this procedure, this strategy may prove limited in cases with small pseudoaneurysms. We describe the complete hemostasis of the pseudoaneurysm that was successfully achieved with endovascular treatment using the Perclose ProGlide suture-mediated closure system without using direct sheath insertion into the lumen of pseudoaneurysm. Our method may be effective in the repair of refractory pseudoaneurysms, in which direct sheath insertion is challenging.

<Learning objective: To understand the potential risk and management of pseudoaneurysm which is associated with percutaneous catheterization.

To understand the treatment options for pseudoaneurysm with endovascular method.>

Introduction

A pseudoaneurysm is a complication that can occur after trans-femoral or trans-brachial artery catheterization [1], [2], [3]. The treatment of such pseudoaneurysms may range from invasive methods, such as open surgical repair to less invasive methods, such as ultrasound-guided compression, coil occlusion, stent graft exclusion, and thrombosis by direct injection of thrombin [2]. Recently, suture-medicated closure devices have been used to treat iatrogenic pseudoaneurysms. Ibrahim et al. reported a novel interventional method for the treatment of iatrogenic femoral artery pseudoaneurysms using the Perclose ProGlide system (Abbott Vascular Devices, Redwood City, CA, USA) [4]. However, the need for the direct insertion of a sheath into the lumen of the pseudoaneurysm as the initial step of the procedure may limit its application in small pseudoaneurysms [4]. In clinical practice, refractory pseudoaneurysms with inadequate space to insert a sheath are sometimes encountered. This study reports a modified percutaneous hemostasis approach using the Perclose ProGlide suture-mediated closure system to treat an iatrogenic brachial artery pseudoaneurysm without direct sheath insertion into the lumen of the pseudoaneurysm.

Case report

This case study has been approved by our institutional review board (2838-R). Written informed consent for the submission and publication of this case report, including images and associated text, was obtained from the patient in line with the Committee on Publication Ethics (COPE) guidance.

A 72-year-old man with intermittent claudication was referred to our hospital for endovascular therapy. Magnetic resonance angiography showed a total occlusion of his right iliac artery. The patient had a medical history of peripheral artery disease with intermittent claudication. No differential diagnoses were identified. Endovascular therapy was performed for the right iliac artery using a bidirectional approach involving the right femoral artery and left brachial artery. The team successfully crossed the wire through the chronic total occlusion site and deployed a self-expanding nitinol stent (SMART; Cordis, Miami Lakes, FL, USA). After endovascular therapy, hemostasis of the left brachial artery access site was achieved with manual compression. However, the patient reported pain and swelling at the brachial puncture site after several hours following manual compression. A systolic bruit was identified at the swelling site. Ultrasound echography revealed an 8 × 12-mm-sized pseudoaneurysm (Fig. 1a, b). Therefore, manual compression with ultrasound guidance was attempted for more than 1 hour. However, it was difficult to collapse the pseudoaneurysm cavity because of its thick and winding neck (Fig. 1a, b). Accordingly, hemostasis using the percutaneous method with the Perclose ProGlide was attempted.

Fig. 1.

Ultrasound image showing an 8 × 12-mm-sized pseudoaneurysm on the upper outer side of the brachial artery.

Since the lumen of the pseudoaneurysm was very small, direct insertion of the sheath seemed impossible. Therefore, the team tried to puncture the pseudoaneurysm using an 18-G intravenous cannula needle under contrast-enhanced ultrasound guidance that showed the pseudoaneurysm and its neck (Video 1). The team also attempted to pass a 0.035-inch radifocus wire (Terumo, Tokyo, Japan) from the venous cannula through the neck. However, the 0.035-inch radifocus wire, which was easily advanced into the soft tissue, could not be passed into the brachial artery through the neck of the pseudoaneurysm (Video 2).

To pass the wire through the neck while maintaining the torque response, it was considered crucial to puncture the pseudoaneurysm at an optimal angle. Therefore, a 4-Fr sheath was inserted from the left radial artery, and the details of the neck of the pseudoaneurysm were identified using angiography (Video 3). This allowed for successful puncture of the pseudoaneurysm using a 22-G intravenous cannula needle at an optimal angle. Finally, a 0.014-inch wire (Hi-torque command; Abbott Vascular, Santa Clara, CA, USA) was successfully passed through the neck and advanced upstream into the brachial artery (Video 4). A Corsair armet microcatheter (Asahi Intecc, Tokyo, Japan) was inserted in the inner cylinder of the 5-Fr sheath, and the sheath was successfully inserted into the pseudoaneurysm using a 0.014-inch wire (Fig. 2a, b). Subsequently, the 0.014-inch wire was replaced with a 0.035-inch radifocus wire and passed through the neck, and the Perclose ProGlide was used to occlude the neck of the pseudoaneurysm (Fig. 3). The final angiography showed complete hemostasis (Video 5).

Fig. 2.

To reduce the gap between the inner sheath and the 0014-in. wire, a Corsair armet (Asahi Intecc) is inserted in the inner cylinder of the sheath.

Fig. 3.

After placement of a sheath in the brachial artery through the neck of the pseudoaneurysm, a 0.035-in. radifocus wire is advanced from the sheath. Occlusion of the neck using a suture-mediated closure system (Perclose ProGlide; Abbott Vascular Devices) is performed by placing a wire in the brachial artery.

The total operation time was approximately one hour. After hemostasis, the pseudoaneurysm did not recur. The patient was discharged 2 days after the procedure and followed up for 10 months in the outpatient clinic. We confirmed that the pseudoaneurysm had not recurred.

Discussion

In this case, complete hemostasis was successfully achieved using a percutaneous method with the Perclose ProGlide for a refractory iatrogenic pseudoaneurysm of the brachial artery, which conventionally requires surgical repair. To use this percutaneous method with Perclose Proglide, few criteria should be met. Specifically, the hematoma must have a neck, be free of infarction, be close to the epidermis, and have a certain diameter of the vessels. There were three reasons for using the percutaneous approach in this case. First, the vessel diameter at the puncture site was approximately 10 mm, which was sufficient to accommodate the Perclose ProGlide in the artery. Second, the puncture site (origin of the neck) was sufficiently far from the radial and ulnar artery bifurcations. Third, the subcutaneous tissue was sufficiently thick to use the Perclose ProGlide.

Previous studies have reported that pseudoaneurysms increase the duration of hospital stay and mortality rates, especially when surgical treatment is required [5,6]. In addition to surgical repair, the treatment approaches for iatrogenic pseudoaneurysms include ultrasound-guided compression, coil occlusion, stent graft exclusion, and thrombosis by direct injection of thrombin [2]. The most common treatment has been the injection of thrombin into a pseudoaneurysm cavity, which causes a thrombus and fills the cavity with a clot in 80%–100% of cases [7,8]. However, thrombin application is hazardous in some cases and may cause complications, such as intra-arterial thrombosis or anaphylactic reactions [9]. Moreover, fatal side effects of allergic reactions to thrombin have been reported [10].

The essential advantage of this method over that of Ibrahim et al. is that the initial direct sheath insertion into a pseudoaneurysm cavity is not required. Sometimes, in daily clinical practice, clinicians encounter pseudoaneurysms with a small lumen due to incomplete thrombus formation. In our case, if the lumen of the pseudoaneurysm had been large, the sheath could have been safely inserted using a 0.035-inch wire; however, it was difficult and dangerous to insert the sheath initially into the pseudoaneurysm owing to its small cavity. Therefore, a 22-G intravenous cannula needle was used, and a 0.014-inch wire was manipulated through the tiny neck of the pseudoaneurysm and advanced upstream in the brachial artery.

Additionally, we opted to insert a Corsair armet into the 5-Fr sheath's inner cylinder to successfully replace the 0.014-inch wire with a 0.035-inch wire, resulting in the advancement of the Perclose ProGlide upstream in the brachial artery and achieving complete hemostasis. Inserting the Corsair armet into the sheath reduced the gap between the 0.014-inch wire and the sheath. We can also use the ICHIBANYARI PAD2 (Kaneka Medix, Osaka, Japan) because the tip is thin and adequately rigid to penetrate the skin.

This strategy allows the use of a percutaneous hemostasis method with the Perclose ProGlide system for refractory pseudoaneurysms with small cavities, which are difficult to manage with a conventional strategy.

In conclusion, this novel interventional technique using the Perclose ProGlide could be a valid option for treating iatrogenic pseudoaneurysms. This method may allow effective repair of refractory pseudoaneurysms when sheath insertion is challenging. Future studies and accumulation of case report data are needed to further explore the potential of this novel technique.

Consent

The authors confirm that a written informed consent for the submission and publication of this case report, including images and associated text, has been obtained from the patient in line with the Committee on Publication Ethics (COPE) guidance.

Presentation at a meeting or conference

None.

Funding sources

None.

Ethical approval

This study was approved by the institutional review board of the Tokyo Women's Medical University. Reference number: 2838-R.

Conflict of interest

Yusuke Inagaki and Masashi Nakao have nothing to disclose. Hiroyuki Arashi and Junichi Yamaguchi belong to the Clinical Research Division for Cardiovascular Catheter Intervention financially maintained by Abbott Vascular, Boston Scientific, Medtronic, and Terumo.