We report a case of iatrogenic claudication as a result of a misplaced percutaneous arterial closure device (PACD) used to obtain hemostasis after cardiac catheterization. The patient presented one week after his procedure with complaints suggestive of right lower extremity claudication. Computed tomographic angiography demonstrated a near total occlusion of the right common femoral artery from a PACD implemented during the cardiac catheterization. The use of PACD’s to obtain rapid hemostasis is estimated to occur in half of all cardiac catheterizations. Ischemic complications as a result of these devices must be considered when evaluating post procedural patients with extremity complaints

Chow, Evelyn

Duvall, W. Lane

Hermann, Luke

English

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We report a case of iatrogenic claudication as a result of a misplaced percutaneous arterial closure device (PACD) used to obtain hemostasis after cardiac catheterization. The patient presented one week after his procedure with complaints suggestive of right lower extremity claudication. Computed tomographic angiography demonstrated a near total occlusion of the right common femoral artery from a PACD implemented during the cardiac catheterization. The use of PACD’s to obtain rapid hemostasis is estimated to occur in half of all cardiac catheterizations. Ischemic complications as a result of these devices must be considered when evaluating post procedural patients with extremity complaints. [West J Emerg Med. 2010; 11(5):512-513.

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Western Journal of Emergency Medicine

Iatrogenic Claudication from a Vascular Closure Device after Cardiac Catheterization

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UC IrvineWestern Journal of Emergency Medicine: Integrating Emergency Care with Population HealthTitleIatrogenic Claudication from a Vascular Closure Device after Cardiac CatheterizationPermalinkhttps://escholarship.org/uc/item/7b41w1frJournalWestern Journal of Emergency Medicine: Integrating Emergency Care with Population Health, 11(5)ISSN1936-900XAuthorsHermann, LukeChow, EvelynDuvall, W. LanePublication Date2010Copyright InformationCopyright 2010 by the author(s).This work is made available under the terms of a Creative Commons Attribution-NonCommercial License, available at https://creativecommons.org/licenses/by-nc/4.0/ Peer reviewedeScholarship.org Powered by the California Digital LibraryUniversity of CaliforniaVolume XI, no. 5  :  December 2010 512 Western Journal of Emergency MedicineCase RepoRtIatrogenic Claudication from a Vascular Closure Device after Cardiac CatheterizationLuke HermannEvelyn ChowW. Lane Duvall	 Mt.	Sinai	School	of	MedicineSupervising Section Editor:	Shahram	Lotfipour,	MD,	MPHSubmission	history:	Submitted	May	13,	2009;	Revision	Received	August	26,	2009;	Accepted	May	24,	2010Reprints	available	through	open	access	at	http://escholarship.org/uc/uciem_westjemWe	report	a	case	of	iatrogenic	claudication	as	a	result	of	a	misplaced	percutaneous	arterial	closure	device	(PACD)	used	to	obtain	hemostasis	after	cardiac	catheterization.	The	patient	presented	one	week	after	his	procedure	with	complaints	suggestive	of	right	lower	extremity	claudication.	Computed	tomographic	angiography	demonstrated	a	near	total	occlusion	of	the	right	common	femoral	artery	from	a	PACD	implemented	during	the	cardiac	catheterization.	The	use	of	PACD’s	to	obtain	rapid	hemostasis	is	estimated	to	occur	in	half	of	all	cardiac	catheterizations.	Ischemic	complications	as	a	result	of	these	devices	must	be	considered	when	evaluating	post	procedural	patients	with	extremity	complaints.	[West	J	Emerg	Med.	2010;	11(5):512-513.]CASE REPORTA 44 year-old-male with a history of coronary artery disease and recent cardiac catheterization presented to the emergency department complaining of right lower extremity pain and numbness associated with ambulation. The symptoms began the day after the catheterization was performed and had progressively worsened. On presentation, the patient’s vital signs were normal and he appeared comfortable. Examination of the arterial puncture site demonstrated a well-healing wound with no appreciable mass, Figure 1.	Computed	tomography	angiogram	with	three	dimen-sional	reconstruction	demonstrating	a	partial	occlusion	of	the	right	common	femoral	artery	associated	with	a	percutaneous	arterial	closure	device.Figure 2.	Computed	tomography	angiogram	demonstrating	de-creased	caliber	of	the	right	superficial	femoral	artery	as	a	result	of	a	partial	occlusion	from	a	misplaced	percutaneous	arterial	closure	device.Western Journal of Emergency Medicine 513 Volume XI, no. 5  :  December 2010hematoma or surrounding erythema noted. Strong femoral pulses without bruit were present bilaterally; however, pulses were decreased distal to the femoral artery puncture site. The right lower extremity was warm to the touch without pallor or mottling and with no appreciable sensory deficit.A doppler ultrasound of the right groin demonstrated normal flow in the right common femoral artery and vein with no evidence of a pseudoaneurysm. Subsequently, computed tomography (CT) angiography of the lower extremities was performed. The CT angiography demonstrated near total occlusion of the right common femoral artery just above the bifurcation and extending into the right profunda femoral artery associated with a percutaneous arterial closure device (PACD)[Figures 1 and 2]. The patient was admitted to the hospital and scheduled for surgical repair of the stenosis the following day. At the time of surgery, a flap from a Perclose PACD, along with a large blood clot underneath it, were found in the femoral artery. These were removed with return of equal and normal distal pulses.DISCUSSIONPACD have been proposed as an alternative to manual compression to achieve hemostasis at the arterial puncture site following cardiac catheterization.1,3 It is estimated that PACDs are used to achieve hemostasis in 50% of all percutaneous coronary procedures.1 Commonly used devices employ either collagen plugs or suture-mediated closure of the arterial puncture site. The potential benefits of these devices over standard manual compression include decreased time to hemostasis, earlier ambulation and ultimately, earlier discharge of patients post catheterization.1,3The commonly reported complications of closure devices include pseudoaneurysm, arteriovenous fistula, hematoma, femoral artery thrombosis and bleeding.1,2,3 Ischemia resulting from suture-mediated devices being deployed within the artery and arterial stenosis from suture-mediated devices are less often encountered, reported in approximately 0.2% of cases in one study of over 4,500 patients.4 The largest case series to specifically evaluate claudication secondary to PACD in percutaneous intervention patients suggests a similar incidence.5 In this single center study that evaluated approximately 4,000 patients over a one-year period, nine cases of iatrogenic claudication as a result of PACD placement were identified.6 Although pain consistent with claudication in the affected extremity was the most common presenting complaint, patients also presented with primary complaints of numbness, extremity fatigue and groin pain, complicating early diagnosis. Additionally, Arterial Brachial Index (ABI) measurements were normal in two patients in the group, suggesting that ABIs at rest are not sensitive enough to rule out the diagnosis. This is likely a reflection of the proximal location of the stenosis, particularly in patients with otherwise normal circulation whose collateral blood flow may be enough to provide adequate perfusion at rest.5 It has been suggested that performing ABIs after exercise in this group of patients would demonstrate a stenosis of clinical significance.5Definitive diagnosis of post procedural arterial stenosis can be made accurately with duplex ultrasound, demonstrating increased turbulence and velocity of the affected artery in comparison to the unaffected side.5Alternately, magnetic resonance or CT angiography allows adequate visualization to identify an obstructive lesion.5Identification of clinically significant arterial stenosis is important as surgical intervention or possibly percutaneous balloon angioplasty is required to relieve the obstruction.5,6 CONCLUSIONThe use of PACD to obtain hemostasis following cardiac catheterization is increasingly common. Given the complications associated with their use, ischemia from improperly placed closure devices should be considered in the differential diagnosis of all patients presenting with lower extremity pain or numbness after femoral artery cannulation.Address for Correspondence: Luke	Hermann	MD,	Director	Chest	Pain	Unit,	Associate	Professor,	Department	of	Emergency	Medi-cine,	The	Mount	Sinai	School	of	Medicine,	One	Gustave	Levy	Place,	New	York,	NY	10029.	Email	luke.hermann@mssm.eduConflicts of Interest:	By	the	WestJEM	article	submission	agreement,	all	authors	are	required	to	disclose	all	affiliations,	funding	sources,	and	financial	or	management	relationships	that	could	be	perceived	as	potential	sources	of	bias.	The	authors	disclosed	none.REFERENCES1.	 Koreny	M,	Riedmuller	E,	Nikfardjam	M,	et	al.	Arterial	puncture	closing	devices	compared	with	standard	manual	compression	after	cardiac	catheterization:	systematic	review	and	meta-analysis.	JAMA	2004;291:350–72.	 Shammas	NW,	Rajendran	VR,	Alldredge	SG,	et	al.	Randomized	comparison	of	Vasoseal	and	Angioseal	closure	devices	in	patients	undergoing	coronary	angiography	and	angioplasty.	Catheter Cardiovasc Interv.	2002	Apr;55(4):421-5.3.	 Nikolsky	E,	Mehran	R,	Halkin	A,	et	al.	Vascular	complications	associated	with	arteriotomy	closure	devices	in	patients	undergoing	percutaneous	coronary	procedures:	a	meta-analysis.	J Am Coll Cardiol.	2004	Sep	15;44(6):1200-9.4.	 Applegate	RJ,	Grabarczyk	MA,	Little	WC,	et	al.	Vascular	Closure	Devices	in	Patients	Treated	With	Anticoagulation	and	IIb/IIIa	receptor	Inhibitors	During	Percutaneous	Revascularization.	J Am Coll Cardiol. 2002	July;40(1):	78-83.5.	 Jang	JJ,	Kim	M,	Gray	B,	et	al.	Claudication	secondary	to	Perclose	use	after	percutaneous	procedures.	Catheter Cardiovasc Interv.	2006	May;67(5):687-95.6.	 Dregelid	E,	Jensen	G,	Daryapeyma	A.	Complications	associated	with	the	Angio-Seal	arterial	puncture	closing	device:	intra-arterial	deployment	and	occlusion	by	dissected	plaque.	J Vasc Surg.	2006	Dec;44(6):1357-9.Claudication from a Vascular Closure Device  Hermann et al.

Arterial puncture closing devices compared with standard manual compression after cardiac catheterization: systematic review and meta-analysis.

Claudication secondary to Perclose use after percutaneous procedures. Catheter Cardiovasc Interv.

Complications associated with the Angio-Seal arterial puncture closing device: intra-arterial deployment and occlusion by dissected plaque. J Vasc Surg.

Randomized comparison of Vasoseal and Angioseal closure devices in patients undergoing coronary angiography and angioplasty. Catheter Cardiovasc Interv.

Vascular Closure Devices in Patients Treated With Anticoagulation and IIb/IIIa receptor Inhibitors During Percutaneous Revascularization. J Am Coll Cardiol.

Vascular complications associated with arteriotomy closure devices in patients undergoing percutaneous coronary procedures: a meta-analysis. J Am Coll Cardiol.

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Iatrogenic Claudication from a Vascular Closure Device after Cardiac Catheterization

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