TAA

TAA, a 75 year old lady who is ADL independent, was referred to us for late presentation of myocardial infarction. We have just completed a difficult angioplasty to the RCA via right femoral route which we closed percutaneously with a Proglide device. We noted absent femoral pulse post closure. Peripheries were cool and pulse absent distally on affected site. The patient however remained pain free and asymptomatic. 

Her blood test was within normal range with Hemoglobin levels of 10.7 g/dL. Urgent bedside doppler ultrasound revealed absent flow across right Common Femoral artery. 

Angiogram of the lower limb prior to closure revealed normal common femoral artery with no significant stenosis or calcification. The puncture was appropriate and not too high. After diagnosing acute occlusion via ultrasound doppler, a repeat angiogram shot from the left side confirmed no flow from common femoral artery.  
pre closure.mpg
post closure.mpg
dsa.mpg

Via access from the left femoral artery, the initial sheath was replaced with a Slender 7 sheath. A JR 3.5, 5F guiding catheter was introduced via a Crossover Sheath to the Right Femoral Artery. Multiple attempts to cross the lesion failed. However, it did establish minimal flow down the artery revealing a "puckered" lesion. Runthrough Floppy, Fielder XT and Command wires were used in that order. With much difficulty, we successfully wired into the popliteal artery. The initial suspicion of thrombus was refuted when there was no thrombus aspirated via Export Suction Catheter. The small tight lesion was predilated with a Ryurei 3.0/20mm semi compliant balloon at 20 atm. Not surprisingly, there was a leak noted after dilation which we presumed was the original puncture site. We initially planned to use a covered stent but deferred as we do not have an appropriate length stent at that moment. The patient was also planned for a staged PCI Left system with limited vascular access. Hence we decided for a prolonged balloon inflation with a PTA OTW Mustang 5.0mm/40mm/135 cm at 6-8 atm for 8 minutes for a total time of 40 minutes. The leak gradually sealed off. She was sent to the CCU for monitoring. 
dsa post wiring.mpg
dsa post balloon.mpg
final dsa.mpg

Although percutaneous closure is an effective method in femoral access care, we must be prepared of its potentially rare but dangerous complications that may arise and manage them without delay. It may be a good practice to assess the femoral pulse and distal pulse after usage of such devices. Fortunately, vascular surgery can still be prevented with prompt intervention from Peripheral Vascular Intervention Team.