80 years old male, DM, hypertension, dyslipidemia.
Patient presents with a femoropopliteal blockage and a humid gangrene of 4th and 5th toes in his right foot requiring minor amputation.
We practice an antegrade echo-guided access in the right common femoral artery (CFA). If previous sonography or angio CT shows iliofemoral permeability and a patent/ normal proximal segment of superfi cial femoral artery (SFA), we usually proceed with this kind of strategy for arterial access for endovascular repair.
First, locate the femoral bifurcation and check if there is anterior/calcified plaque in the common femoral artery (CFA) (Fig. 1). Perform the echo-guided puncture in a transversal way and shift to a longitudinal vision to ensure the progression of the guidewire into the SFA (Fig. 2-4) and avoid any progression into the profunda femoral artery (PFA) as this happens quite often.
A 6F 13 cm length introducer sheath (Flexor Check-Flo by Cook Medical) is then placed and an angiography is done to ensure the right position of the sheath and to evaluate the initial segment of de SFA.
A tight short stenosis was found in the middle portion of SFA (Fig. 5) and a plain old balloon angioplasty (POBA) (Cook Advance 0.35, 6x40) is performed. Nice angiographic result with no dissection or residual stenosis was obtained (Fig. 6) and we decided not to implant a stent.
The option of DCB could be discussed, but it was a fi rst attempt and the DCB technology is not available in our shelf.
The popliteal segment was normal (Fig. 7), and distally we found a stenosis in the proximal portion of tibial anterior artery (Fig. 8). Again, POBA, our first option (Cook Advance LP 0.14 3x200). The procedure was done with a good result Fig. 9).
To close the femoral access site, a Terumo FemoSeal vascular closure device was used. Sonographic control was done to ensure correct deployment
Image echo 1. Thread the FemoSeal device over the guidewire and insert the sheath and dilator into the artery (FemoSeal deployment Step 1). Grip and squeeze the wings of FemoSeal
Safety Catch, lift and retract FemoSeal Safety Catch slowly along with the guidewire until completely removed (FemoSeal deployment Step 2).
NOTE: Hold the device in position with the opposite hand. When FemoSeal Safety Catch with dilator has been retracted a few centimeters (2 - 4 cm), blood should appear in the proximal part of the sheath, verifying that the sheath is in the artery.
Image echo 2. Deploy the Inner Seal by pressing down the button completely in one cintinous movement ( FemoSeal deployement Step 3).
Image echo 3. Pull back the FemoSeal device until the depressed button springs back (FemoSeal deployment Step 4). The Inner Seal establishes hemostasis.
Image echo 4. Maintain suture tension while deploying the Outer Locking Disc, by completely pressing down the button again (FemoSeal deployment steps 5-6). Remove the FemoSeal device, verify hemostasis and cut the suture below the skin level using a sterile instrument.
As previously decided, we proceeded with amputation of 4th and 5th toes with posterior good healing and ambulation conserved. The patient was discharged 24hrs after the operation. This could have been a same day discharge patient but the amputation made us decide that an overnight hospital stay was necessary. Complete healing was achieved in a month and so limb salvage.
My tips and tricks
We prefer FemoSeal because it is very easy to use, quick to achieve complete hemostasis and reduce the time to ambulation, a very important factor in elderly patients. With the use of FemoSeal we can also avoid skin lesions caused by compressive bandages, as extra compression is not necessary.
Dr. Víctor González Martínez
Senior Vascular Surgeon
Hospital Universitari de Vic. Barcelona, Spain
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