Endovascular Treatment of a Ruptured Profunda ... - Springer Link

Cardiovasc Intervent Radiol (2010) 33:182–186 DOI 10.1007/s00270-009-9534-6

CASE REPORT

Endovascular Treatment of a Ruptured Profunda Femoral Artery Branch After Fogarty Thrombectomy of a Femoro-Femoral Crossover Arterial Graft: A Case Report and Review of the Literature Eirini Manousaki Æ Dimitrios Tsetis Æ Theodoros Kostas Æ Asterios Katsamouris

Received: 2 November 2008 / Accepted: 28 January 2009 / Published online: 17 March 2009 Ó Springer Science+Business Media, LLC 2009

Abstract We present a very rare case of a life-threatening rupture of a profunda femoral artery distal branch after a Fogarty thrombectomy of a thrombosed crossover synthetic graft between the ipsilateral common femoral artery and a contralateral iliac-popliteal graft; the bleeding profunda femoral artery branch was successfully embolized with metallic coils through the axillary artery approach. Keywords Fogarty catheter embolectomy Fogarty catheter thrombectomy Femoro-femoral crossover arterial graft Profunda femoral artery Arterial rupture Coil embolization

tip of the catheter or vessel wall bursting during balloon overdistension [4–6]. Transcatheter embolization is an accepted and effective treatment method for injuries of middle and small size vascular segments, offering the advantage of rapid and safe occlusion in a less invasive manner [4, 7]. We report a rare case of a right profunda femoral artery (PFA) distal branch rupture as a result of embolectomy of a thrombosed crossover graft between the ipsilateral common femoral artery (CFA) and a left iliac-popliteal graft, treated successfully with transcatheter coil embolization through the left axillary artery approach, and make a review of the relative literature.

Introduction Case Report Since the time of its introduction in 1963, Fogarty balloon catheter has become an invaluable tool in the hands of the vascular surgeon. Complications after balloon catheter thrombectomy are generally underestimated and the related morbidity is considerable [1]. Arterial perforation or rupture, often leading to pseudoaneurysm or arteriovenous fistulae (AVF) formation is described among the most serious [2–5]. Small-size vessels appear more prone to such complications. The associated mechanism responsible is either mechanical rupture due to direct perforation by the E. Manousaki D. Tsetis (&) Department of Radiology, Medical School of Crete, University Hospital of Heraklion Crete, Voutes, 71110 Heraklion, Crete, Greece e-mail: [email protected] T. Kostas A. Katsamouris Department of Vascular Surgery, University Hospital of Heraklion Crete, Heraklion, Crete, Greece

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A 73 year-old male with a history of severe peripheral arterial obstructive disease presented with acute left lower limb iscemia. A synthetic PTFE (Poly-Tetra-Fluoro-Ethylene) graft, tapered in shape (from 8 to 6 mm), had been placed 3 years ago between the left external iliac artery and the ipsilateral popliteal artery at the level just above the knee joint, in order to by-pass an extended occlusion of the common, deep and superficial femoral arteries. The graft had been thrombosed 2 months prior to current admission, as a result of ipsilateral common iliac artery occlusion. At that time, unsuccessful graft thrombectomy at the site of proximal anastomosis with the external iliac artery was followed by the insertion of an 8 mm PTFE crossover graft between the right CFA and the proximal part of the old graft which was successfully thombectomized, establishing good run off into the ipsilateral popliteal artery. During current admission, colour Doppler ultrasonography revealed thrombosis of the combined synthetic

E. Manousaki et al.: Endovascular Treatment of a Ruptured Profunda Femoral Artery Branch

graft. The patient underwent successful emergency thrombectomy of the graft, which was exposed through a longitudinal incision in the left groin, with a 4F Fogarty catheter. Restoration of left popliteal artery pulses was achieved intraoperatively and the on-table arteriogram showed no evidence of stenosis in both anastomoses of the crossover bypass graft and at the distal anastomosis with the popliteal artery. A few hours later, the patient developed a painful swelling of the right thigh and the haematocrit dropped significantly to 32%, measuring 38% preoperatively. Computed tomography depicted an intramuscular hematoma in the posterior compartment of the right proximal thigh with active contrast extravasation (Fig. 1). An emergency angiogram through the left axillary approach showed active extravasation at the level of

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fourth perforating branch of the distal segment of the right PFA (Fig. 2) related to disruption during thrombectomy. Prompt endovascular intervention was decided at that point. The left axillary approach was used and a 110 cmlong 5F hydrophilic vertebral-type catheter (Glidecath, Terumo) was advanced superselectively to the origin of the bleeding branch over a 0.035 inch Terumo guide-wire. Two 0.035 inch platinum coils (Target, Boston Sc) of 4 mm in diameter were successfully deployed. Extravasation ceased immediately (Fig. 3) and the haematocrit stabilized to 30%, without the need for blood transfusion. After the first 48 h the thigh haematoma regressed and the haematocrit elevated. The patient was discharged after an uneventful post-operative period of five days.

Fig. 1 Pre- (A) and postcontrast (B) serial computed tomography scan showing posterior compartment muscle swelling in the right thigh in the presence of intramuscular hematoma with active bleeding (arrow)

Fig. 2 Conventional angiography performed through the left axillary artery which shows the way that the right CFA is connected with the crossover arterial graft (A) and the active contrast extravasation at the level of the fourth perforating branch of the right profunda femoral artery (B)

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Fig. 3 Completion arteriogram demonstrating the successful deposition of the coils and the hemorrhage cessation

Regular follow-up for the next 78 months has revealed graft patency. The patient is in a good condition.

Discussion Since its introduction in casual vascular practise, Fogarty balloon catheter has undoubtedly been used successfully for the salvage of many thousands of ischemic limbs; even though no relevant meta-analysis exists in the literature, several series studies conclude to its effectiveness independently. However, a variety of potentially limbthreatening conditions can be encountered with its use [2]. The incidence of complications is generally underestimated [1] or not reported. Collective experience in this kind of injuries is mainly restricted to a few case or small series reports. The majority of the injuries described refer to arterial perforation, pseudoaneurysm, AVF formation

[2–5], as well as arterial thrombosis provoked by accidental intima removal, wall dissection and catheter tip separation [8]. Late complications of accelerated atherosclerosis and diffuse arterial narrowing [9, 10] have also been reported. The most commonly affected vessels are the peroneal and posterior tibial arteries injured during thrombectomy or embolectomy in the femoropopliteal region [4, 6, 8]. In the vast majority of cases the procedure is performed in a blind fashion; this can potentially lead to vascular trauma far away from the vascular bed of interest, i.e renal artery injury during retrograde thrombectomy of an occluded aortofemoral graft [11]. In our case the curved route of the Fogarty catheter inside the crossover graft probably led to overestimation of the length of the area needed to be thrombectomised, thus resulting in injury of a PFA distal branch. In addition, the acute angle of the anastomosis between the graft and the right CFA might also have contributed to arterial injury. With the slightest suspicion of Fogarty catheter-related arterial injury diagnostic angiography should be prompted, since physical findings may appear vague during the early postoperative period [4]. Aggressive systemic heparinisation typically administered after Fogarty embolectomy can provoke rapid bleeding which can be life-threatening [4]. Limited experience has been gathered in the literature regarding iatrogenic trauma of the PFA and its branches; this has been associated to unfavourable events during thromboembolectomy (Table 1) or orthopaedic surgery [7, 12]. Fogarty-catheter related trauma of the PFA territory can present in the forms of rupture and haemorrhage, pseudoaneurysm or AVF formation. Most of these cases have been recognised intraoperatively [13–16] and the decision for prompt surgical repair of an arterial rupture [14] and an AV fistula [15] has lead to safe rehabilitation. Pseudoaneurysm formation does not seem to require active treatment, as it may exist silently or even be diagnosed incidentally [3, 13]. Interestingly, one of these cases was related to a combined axillofemoral and femoral crossover graft that was complicated by the formation of an asymptomatic pseudoaneurysm [3]; the above is in accordance

Table 1 Reported experience on trauma of the profunda femoral artery caused by the use of Fogarty balloon catheter Author

Complication

Identification

Symptoms

Treatment

Sequelae

Nevelsteen A

Rupture

4 days

Thigh swelling, severe ischemia

Surgical repair

Major amputation

Albrechtsson U

Pseudoaneurysm

2 years

None

Observation

None

Parsa F

AV fistula

6 weeks

Tissue loss

Surgical repair

Recovery of tissue loss

Dainko E

Catheter tip separation

Intraoperatively

None

Observation

None

Foster J

Rupture

Intraoperatively

None

Surgical repair

None

Stoney R

Pseudoaneurysm

Intraoperatively

None

Observation

None

Lord RS

AV fistula

Intraoperatively

None

Surgical repair

None

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with our suggestion that the complex hemodynamic route of the catheter during embolectomy exposes the vasculature to extra hazard. Arterial rupture is definitely an emergency, which may not always become obvious during surgery. Fogarty-catheter related iatrogenic rupture of the PFA has been reported to become clinically evident even 4 days post operatively, with the critical necessity of major amputation [1]. In our case, the few hours needed for the clinical diagnosis of arterial rupture and haemorrhage jeopardized the patient’s life. Undoubtedly intervention has to be prompt and effective. Surgical exploration and repair of the injured PFA branches can be laborious and complex, due to their anatomic location deep within the muscle components of the thigh. Especially in active extravasation, the swelling and haemorrhagic infiltrate make it more difficult for the surgeon to identify and ligate the injured deep femoral artery branch. In addition the—virtually unavoidable—sacrifice of collateral vessels during surgical exposure may increase the overall morbidity further [1, 17], especially in patients with an atherosclerotic profile as in our case. In contrast, transcatheter coil embolization, performed on the same session with diagnostic angiography, appears the most preferable treatment method for deep femoral vasculature injuries and in experienced hands ensures rapid and successful exclusion of pseudoaneurysms and cease of haemorrhage in ruptured segments [7, 17, 18]. To our knowledge, this is the first case reporting successful transcatheter embolization on an emergency basis of a PFA distal branch active bleeding as a result of Fogarty embolectomy of a thrombosed femoro-femoral crossover graft. In our case, the hostile femoral regions, caused by the multiple previous surgical operations, led us to use the axillary access for both diagnostic angiography and endovascular treatment. Coil embolization for the treatment of pseudoaneurysms, partial transections and especially arteriovenous fistulae is most successful when coils are deployed both proximal and distal to the site of injury. This prevents retrograde arterial filling through recruited collaterals. In such cases a microcatheter can be helpful [12]. On the other hand for more peripheral branches, embolization of the proximal portion of the injured artery may be sufficient [17]. In our case the distal site of haemorrhage and the high flexibility and trackability of the 5F hydrophilic catheter allowed rapid approach to the target-area and prompt proximal embolization immediately after the third penetrating branch without the need of a microcatheter. Gelfoam and Tris-acryl microsphere particles as well as liquids agents such as N-butyl cyanoacrylate (NBCA) represent alternative embolic agents but carry the risk of needless obliteration of peripheral collaterals. A newer liquid agent Ethylene Vinyl Alcohol Copolymer (Onyx)

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appears advantageous over other liquid embolic agents because it can be delivered in a slower and more controlled manner and has a longer polymerization time with high viscosity. A recent report describes three cases of profunda femoris arterial branch pseudoaneurysmal formation (two penetrating injuries and one iatrogenic trauma) embolized successfully with this agent [7]. In conclusion, routine Fogarty embolectomy should be attempted with caution especially in cases where the hemodynamic route of the Fogarty catheter is not smooth such as is in the case of femoro-femoral arterial crossover bypass grafts. Any suspicion of iatrogenic arterial trauma in profunda femoral artery branches should alert for diagnostic angiography and prompt transcatheter coil embolization. Transaxillary or brachial approach should be considered in cases of hostile groin regions.

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18. Entwisle JJ, De Nunzio M, Hinwood D (2001) Case report: transcatheter embolization of pseudoaneurysm of the profunda femoris artery complicating fracture of the femoral neck. Clin Radiol 56:424–427