An effective method for percutaneous hemostasis of femoral artery by endovascular balloon occlusion via the occluded dorsal pedalis artery approach in a patient with restricted access site

Abstract

Hemostasis of a large-diameter sheath is sometimes problematic, especially for patients with limited approach sites. Here, we describe an effective and safe endovascular method for hemostasis of the femoral artery via the dorsalis pedis artery. The patient was a 75-year-old man who was performing endovascular therapy via the left common femoral artery. A pseudoaneurysm developed, and it was treated via the right common femoral artery. He developed acute coronary syndrome 1 week later, and an intra-aortic balloon pump therapy was inserted via the right femoral artery. Neither radial artery was available, and the right brachial artery was punctured to perform coronary revascularization. When the intra-aortic balloon pump was to be removed, the right dorsal pedis artery was punctured, and hemostasis was achieved without any complications. We conclude that the trans-ankle intervention may be an effective and less invasive technique for percutaneous hemostatic procedures.

Background

Hemostasis after large-diameter sheath insertion in the femoral artery is sometimes problematic. ¹ Especially for hemodynamically unstable patients, mechanical circulatory support such as intra-aortic balloon pump (IABP) and veno arterial extracorporeal membrane oxygenation (VA-ECMO) is inserted from a transfemoral approach. There are some effective and safe methods for VA-ECMO removal by percutaneous approach. ² However, patients with limited approach sites are often observed in daily clinical practice. Trans-tibial access is reported to be a successful and effective technique to treat patients with peripheral artery disease (PAD). ³ However, many PAD patients have occlusion of the below-the-knee (BTK) artery. Even if it is occluded, if the BTK artery can be opened retrogradely, it can be used as an access site. We have reported that intravascular ultrasound (IVUS)-guided wiring in the BTK artery is useful for unidirectional lesion passage. ⁴ In the present report, we describe an effective and safe endovascular method for hemostasis of the femoral artery via occlusion of the ipsilateral dorsal pedalis artery (DPA) by IVUS-guided wiring.

Case presentations

A 75-year-old man with hypertension, PAD, and coronary artery disease presented with claudication of the left lower limb. The ankle-brachial index was 0.71 on the left side, indicating a diagnosis of PAD. ⁵ Enhanced computed tomography showed the left superficial femoral artery (SFA) severe stenosis with calcification. The patient was punctured in the left common femoral artery (CFA) to perform endovascular therapy (EVT). A Seven-Fr guiding sheath (Parent Pro 60^® guiding sheath; Medikit, Tokyo, Japan) was inserted, and EVT was performed. Hemostasis was performed with a hemostatic device (Exoseal^®; Cordis, Miami, USA). Two days later, a pseudoaneurysm developed. Hemostasis was difficult to achieve with duplex ultrasound-guided manual compression, so we attempted EVT for hemostasis. The patient was punctured in the left radial artery, but he was not able to use it, because the left radial artery was too small in diameter on duplex ultrasound, making sheath insertion difficult. Instead, the right CFA was punctured, and we tried a technique combining endovascular balloon blockade and thrombin injection, but hemostasis was difficult to achieve. Finally, hemostasis was achieved with 7 mm balloon expandable covered stent (Lifestream^®; BD, Tokyo, Japan) implantation. Hemostasis of the right CFA was performed with a hemostatic device (Perclose Prostyle; Abbott Vascular, Santa Clara, CA, USA).

One week later, he developed a non-ST-segment elevation myocardial infarction and associated acute heart failure. Coronary angiography showed severe stenosis. The left main coronary trunk (LMT) to the left anterior descending (LAD) artery was most severely diseased, and the proximal portion of the right coronary artery was diseased. He required noninvasive positive pressure ventilation, and an IABP was unintentionally inserted via the right SFA for hemodynamically unstable status because the right CFA had a hematoma, and ultrasonography showed poor delineation. The patient was managed in the intensive care unit for later percutaneous coronary intervention (PCI). At the time of PCI, the right radial artery was severely stenosed, and the 6 Fr sheath could not be inserted. The left CFA had a large hematoma. Therefore, PCI was performed from the right brachial artery. PCI for the LMT to the LAD was performed under a hemodynamically unstable situation, so IABP was continued. The next day, the IABP was to be removed, but the approach site needed to be considered (Figure 1(a)). The patient had just recovered from unstable status and had just experienced bleeding complications at the left CFA puncture site (Figure 1(b)); a puncture site with the lowest possible risk of circulatory effects and bleeding complications was desired. The right DPA was punctured under ultrasonographic guidance. A 0.014-inch guidewire and a 5-Fr guiding sheath (Parent Select 5082^® guiding sheath; Medikit) were inserted (Figure 2(a)). Since the right anterior tibial artery (ATA) was partially occluded, the IVUS-guided parallel wiring technique ⁴ was used to treat the ATA occlusion. After the guidewire crossing and balloon dilation, the retrograde guiding sheath reached the right popliteal artery (Figure 2(b) and (c)). A 7.0 × 100 mm balloon (Senri^®; Terumo, Tokyo, Japan) was delivered to the right CFA (Figure 2(d)). At the time of balloon dilation, IABP and the 8 Fr sheath were pulled out. Manual compression from the body surface was applied to the SFA while balloon tamponade was performed. A 7 mm balloon was insufficient for complete hemostasis, so additional hemostasis was performed with an 8.0 × 40 mm (Senri^®; Terumo; Figure 2(e)). Hemostasis was achieved, and there was no injury of the SFA to ATA, and ATA was well dilated by angiography (Figure 2(f) and (g)). The balloon dilatation time required for hemostasis was ~20 min. Two antiplatelet drugs, aspirin and clopidogrel, were administered after PCI and were taken orally. Also, 4000 units of heparin were administered during this procedure.

Figure 1.

Created by author. (a) Schema of each puncture site. (b) Computed tomography (CT) angiogram of left CFA pseudoaneurysm.

Figure 2.

Angiogram of the endovascular treatment. (a) Wiring through ATA with 0.014-inch wire. (b) Performing EXCAVATOR technique to rewiring into the ATA vessel after inserting 6 Fr sheath via DPA. (c) Wiring through the ATA proximal to the popliteal artery. (d) Before inflation of 7.0 × 100 mm balloon. Eight Fr sheath and IABP are inserted from the SFA proximal. (e) Dilation of 8.0 × 40 mm balloon. (f) Final angiography of SFA shows no injury in SFA. (g) Final angiography of ATA shows no injury in ATA.

Discussion

We demonstrated that this approach to use occluded DPA was an effective EVT for patients who are at a higher risk of circulatory effects and bleeding complications. In this case, hemostasis after SFA sheath removal was successfully achieved in a situation where there were few vessels that could be safely punctured, and complications had to be minimized as much as possible. Although a sheath was inserted through the SFA, hemostasis could have been successfully achieved if a closure device had been available. ⁶ However, the IABP was inserted through the 8-Fr sheath, and there was a risk that the sheath would come out with it when the IABP was removed. And, according to the guidelines for the appropriate use of hemostatic devices available in Japan at that time, hemostasis of the 8 Fr sheath left in the SFA was considered unreliable. We have previously reported percutaneous hemostasis using balloon occlusion.^2,7

There is a risk of thrombus formation when balloon tamponade is performed. Therefore, to avoid those risks, we usually inflate the balloon for ~10 min, deflate it to create flow and check hemostasis, and repeat this procedure until hemostasis is completed.

The left brachial artery was another option for access site, since trans-radial artery approach for the CFA has been reported to achieve a high rate of procedural success with a low rate of complications. ⁸ However, this is the report for the trans-radial artery approach, and sometimes the brachial artery approach is reported to have a higher complication rate. ⁹

In this case, the ability to use the occluded DPA to ATA as an access site contributed to a minimally invasive hemostatic procedure. This is not an easy procedure since it requires treatment of the ATA occlusion. However, if a retrogradely occluded ATA can be opened, it may well be used as an access site. A technique using an ultrasonography-guided approach to an occluded radial artery as an access site has been reported. ¹⁰

In the present case, the obstructed DPA was punctured by ultrasonography to confirm that the needle was inserted into the vessel, and the obstructed ATA could be used as an access site by wiring the obstructed ATA with IVUS. IVUS-guided wiring was a very useful technique in this case. ⁴ Final angiography revealed that there was no injury to the ATA. The blood flow of the ATA was very well, and the DPA pulsation was confirmed by both palpation and Doppler.

Previous studies have reported the efficacy of the pedal approach for EVT. It is a less invasive approach for patients with bad body habitus or comorbidities for intervention. ³ In coronary artery intervention, there is a report that compared to femoral access, radial access showed reduced mortality and major adverse cardiovascular events (MACE) and improved safety, with reductions in major bleeding and vascular complications. ¹¹ Although there is a risk of radial artery occlusion, some practices for prevention are reported. ¹² Although trans ankle artery access may be one of the less invasive approaches in EVT, it is important to select cases that do not worsen the lower extremity prognosis.

This case was completed with no complications, and patency is confirmed for more than 6 months. However, the efficacy and the safety of our method are not known because the number of patients was very small. A much larger study and long-term follow-up are needed to confirm the safety and efficacy of our method.

Conclusions

Using the occluded DPA for the approach site may be useful for managing ipsilateral femoral artery hemostasis without hemodynamical change or bleeding complications.