Cutting Balloon Angioplasty to Relieve Femoral Artery Occlusion Associated with a Vascular Closure Device

BACKGROUND:
Vascular closure devices have been increasingly employed in the setting of endovascular arterial procedures to achieve rapid hemostasis, avoid the discomfort of manual compression, and accelerate patient recovery. However, these devices are not without complication. Among them is arterial occlusion. Traditionally, treatment of such complications have required open surgical repair, which is often undesirable given the co-morbidities common to patients undergoing such procedures. We describe two cases of femoral artery occlusion secondary to the use of suture-mediated vascular closure devices successfully treated with cutting balloon angioplasty.
Case 1: A 79 year old female developed a cold, pulseless right lower extremity immediately following coronary angiography via right femoral access. A Perclose vascular closure device (Abbott, Abbott Park Illinois) had been utilized to close the site of arterial puncture. Angiography from the contralateral groin confirmed occlusion of the right common femoral artery (Figure 1A). The occlusion was successfully traversed with a guidewire. Initially, standard angioplasty of the lesion was attempted without improvement. Repeat angioplasty using a 7mm Cutting Balloon (Boston Scientific, Letterkenny, Ireland) resulted in complete restoration of arterial luminal patency and normal pedal pulses (Figure 1B).
Figure 1

Case 2: A 25 year old male with a history of congenital heart disease presented with complaints of short distance claudication and numbness in the right leg since a cardiac catheterization via right femoral access one day prior. Again, a Perclose device had been utilized to close the site of arterial puncture. Duplex confirmed occlusion of the right common femoral artery. Based on our experience in the aforementioned case, we elected to proceed directly with angioplasty using a 5 mm cutting balloon from a contralateral approach. The angioplasty was successful in cutting the Perclose suture and resulted in successful re-establishment of right lower extremity flow (Figure 2).
Figure 2

DISCUSSION
Occlusive complications secondary to suture mediated closure devices are usually the result of inadvertent posterior wall puncture and subsequent apposition of the anterior and posterior walls by the suture during deployment of the device. Therefore, it is not surprising that initial standard balloon angioplasty failed in Case 1. In fact, further attempts would likely have torn the artery or at best just loosened the suture. In contrast, the atherotomes of the cutting balloon directly addressed the underlying problem by incising and releasing the monofilament suture itself and obviated the need for open surgical intervention in these two patients. To our knowledge, the use of cutting balloon angioplasty for this purpose has not been previously described in the medical literature. Based on our small experience, we believe that this technique has utility in the management of patients who develop arterial occlusion following the use of a suture mediated closure device.