Central Pseudo-aneurysm Formation following Arterial Closure with a StarClose SE Device

Posted By Sehrish Memon
Central Pseudo-aneurysm Formation following Arterial Closure with a StarClose SE Device

Abstract Vascular closure devices are frequently used for hemostasis during endovascular procedures by employing sutures, plug devices (using collagen or hydrogel) or through the use of a metal clip made of nickel and titanium as with the StarClose device. We present a case where a StarClose SE vascular closure device (VCD) was deployed for hemostasis post diagnostic cardiac catheterization and upon repeat access, four days later for coronary intervention, retrograde sheath angiography revealed a pseudo-aneurysm emanating from the center of the StarClose clip. Review of literature indicates StarClose to be safe and effective in achieving hemostasis in majority of endovascular procedures and the incidence of pseudo-aneurysm to be infrequent. Introduction Femoral arterial hemostasis post cardiac catheterization can be achieved through manual compression (MC), mechanical compression or vascular closure devices (VCDs). Although VCDs have been shown to be non-inferior to MC with respect to access site hemostasis and complications, MC is still considered the gold standard for achieving hemostasis [1]. The use of VCDs avoids the need to interrupt anticoagulation, improves patient comfort, provides faster time to ambulation and discharge and reduces healthcare burden by freeing staff resources [2]. In deciding the method of arterial closure, MC versus VCD, one must take into account numerous factors from patient characteristics to the site of arterial puncture to minimize VCD related complications. Keywords access site management, vascular closure devices, pseudo-aneurysm, complications, endovascular procedures, StarClose SE Case Description A 77-year-old man with history of ischemic cardiomyopathy with left ventricular ejection fraction 20-25% and atrial fibrillation was transferred to our hospital post cardiac arrest. He was noted to have positive troponins and was diagnosed with NSTEMI. Anticoagulation was started with a loading dose aspirin 325mg and Plavix 600mg with maintenance dose of 81mg and 75mg respectively, along with intravenous heparin infusion. After stabilization, cardiac catheterization was performed via a right femoral approach, due to limited radial arterial access, revealing multi-vessel coronary artery disease with a syntax score of 16. Hemostasis post-procedure was achieved with a StarClose SE device with no post deployment oozing or delayed hemostasis. He was felt to be at extreme surgical risk and was referred for high-risk percutaneous coronary intervention (PCI). Again, right femoral arterial access was obtained and a 6F sheath was introduced. PCI was performed with the placement of four drug-eluting stents: one in the proximal LAD, a second in the ramus intermedius, and two in the first obtuse marginal. Prior to PCI, retrograde sheath angiography was performed to evaluate the access site for hemostasis and suitability for closure. The femoral arterial cannulation site was noted to be appro

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