Author + information
- Received April 10, 2018
- Revision received April 26, 2018
- Accepted May 1, 2018
- Published online August 6, 2018.
- Nicholas Ierovante, DO and
- Kintur Sanghvi, MD∗ ()
- ↵∗Address for correspondence:
Dr. Kintur Sanghvi, Deborah Heart and Lung Center, 200 Trenton Road, Browns Mills, New Jersey 08054.
- closure devices
- endovascular abdominal aortic aneurysm
- peripheral arterial interventions
- transfemoral aortic valve replacement
We report 2 patients, both men, 87 and 82 years of age, with severe aortic stenosis scheduled for transcatheter aortic valve replacement (TAVR), both with histories of lower extremity peripheral artery disease and endovascular abdominal aortic aneurysm repair with presence of dense bilateral groin scar tissue from prior procedures (Figures 1A and 1B). Both patients were thought to be at high risk for suture-mediated pre-close failure, as well as other access-related complications, and the contralateral femoral approach was not available because of endovascular abdominal aortic aneurysm repair (1,2). Common femoral access was obtained in standard fashion, and prior to upsizing to the TAVR sheath, under fluoroscopic and angiographic guidance using a micropuncture needle and a 0.018-inch wire, the ipsilateral superficial femoral artery (SFA) was accessed. A 4-F micropuncture inner dilator was placed in the SFA attached to a Y connector, the 0.018-inch wire was left in place, a 3-way stopcock was placed, and the remainder of the TAVR was conducted in normal fashion (Figures 2A and 2B).
In the first patient, the Prostar XL (Abbott Vascular, Santa Clara, California) suture-mediated closure device did in fact fail to deploy because of severe calcification and scarring. The aforementioned ipsilateral SFA was upsized to a 7-F sheath, allowing placement of polytetrafluoroethylene-covered nitinol self-expanding Viabahn stents (W.L. Gore and Associates, Flagstaff, Arizona), which repaired the arteriotomy (Figures 3, 4A, and 4B⇓⇓). Closure of SFA access with a Perclose ProGlide (Abbott Vascular) was performed without incident. In the second patient, a Prostar XL suture-mediated closure device repaired the common femoral arteriotomy without complication. Manual pressure was held for SFA hemostasis after removing the microdilator.
In case 1, having SFA access proved to be invaluable, as we were able to quickly deploy the covered stent, preventing major bleeding. These cases demonstrate that prophylactic ipsilateral SFA access can be used to treat large-bore CFA arteriotomy when suture-mediated pre-close fails and contralateral femoral access is not available.
Both authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received April 10, 2018.
- Revision received April 26, 2018.
- Accepted May 1, 2018.
- 2018 American College of Cardiology Foundation