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424 Coiling of peripheral aneurysms
Aer placement, the occluder can be compacted
further with force. To move it signicantly from
its location is dicult and would likely require
snaring and withdrawal. Aer an occluder is
placed, traction on it usually causes it to stretch.
e vessel occluder can be used in a variety of
arteries. is becomes practical in situations
where the artery size that must be obliterated is
more than a few millimeters in diameter. It can
also be used in conjunction with coils.
ENDOVASCULAR MANAGEMENT
OF A POPLITEAL ANEURYSM
Popliteal aneurysms may be excluded with stent–
gra placement (Figure 29.5). ere is usually
some taper between the diameter of the proximal
neck in the distal supercial femoral and proximal
popliteal arteries and the diameter of the distal
neck. Because of this, exclusion usually requires
placement of two separate gras. e distal diam-
eter where a seal would be obtained determines
the size of the distal gra. e stent–gra should
be sized according to its instructions for use. e
distal gra is placed rst so that the larger proxi-
mal gra will have a friction seal with the distal
gra when placed. e proximal gra is sized to
the diameter of the proximal artery seal zone. e
most focal popliteal artery aneurysms are the ones
treated best with exclusion. Type II endoleak can
occur but is rarely an issue since popliteal aneu-
rysms rarely rupture, and their primary mode of
presentation is embolization. e long-term suc-
cess of endovascular exclusion of a popliteal aneu-
rysm is enhanced by vessel size and also by the
quality of the runo. If runo is adequate and the
diameter of the distal vessel is 6 mm or more, long-
term patency is reasonable. Larger popliteal artery
diameters are common in this population, even in
“normal” segments of the artery. e two gras
should overlap by 3–5 cm. A longer overlap is usu-
ally best. At the conclusion of the procedure, a bent
knee lateral view of the reconstruction will help to
determine if there are any technical problems. e
proximal and distal seal zones should each be at
least a few centimeters in length.
A
B
Fig. 29.4 Placement of a vessel occluder in theinternal iliac artery. (A) A sheath is placed in the orifice
of the internal iliac artery. It is usually best to advance the tip of the sheath a little farther than is
necessary. It may pull back a bit during placement, especially if the passage of the occluder straight-
ens the tip of the sheath slightly when it passes. The trilobed occluder device is advanced to the tip
of the sheath. (B)The sheath is withdrawn a little to expose the tip of the occluder device. The device
can also be pushed out gently using its delivery wire. The occluder begins to take its preconfigured
shape. After the occluder is released, a portion of the device is constrained within the neck of the
internal iliac artery, which is a smaller caliber than the aneurysmal segment.
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Endovascular management of a popliteal aneurysm 425
x
x
x
x
A B
C D
Fig. 29.5 Stent–graft treatment of a popliteal artery aneurysm. (A) A focal mid-popliteal artery
aneurysm presents for treatment. There are numerous collaterals from the popliteal artery near
theknee, but there is also a reasonably lengthy and healthy landing zone proximal and distal to
thelesion. (B)IVUS is used to assess the diameters of the proximal and distal landing zones for the
most accurate stent–graft sizing. Oversizing the graft is problematic since infolding can encroach
on the artery lumen. Undersizing the endograft diminishes its friction seal with the artery and also
withthe companion graft. (C) After measuring the diameters of the proximal and distal landing zones,
the distal graft is sized for the diameter of the distal landing zone. The distal graft is placed. Three
to 5 centimeters of normal sized and nontapered artery is desirable for a seal. (D) After placement
of the distal stent–graft, the proximal graft is placed. The proximal graft is sized to the proximal
landing zone using IVUS. The proximal graft is usually a little larger than the distal graft. Three to
5 centimeters or more of overlap between the two grafts are required for a durable seal. Stent–graft
balloon angioplasty is performed within the graft.
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427
30
Puncture site management
OBTAINING HEMOSTASIS
In a manner similar to the performance of open
surgery, wound complications present a low-level
but constant problem. Access-related complica-
tions are still the most common complication of
endovascular procedures. ese complications are
not usually life-threatening but they may add sub-
stantially to the morbidity of the procedure and
may necessitate additional procedures. Obtaining
hemostasis aer a percutaneous intervention has
the same importance as surgical wound closure.
Percutaneous closure devices are not covered in
depth in this text. However, these devices are here
to stay and each has its own learning curve.
Obtaining hemostasis is made safer and simpler
when the arteriotomy site is selected well and the
puncture site managed properly during the pro-
cedure. Puncturing the artery with a satisfactory
technique, holding pressure during exchanges,
using dilators to prepare the tract and the arte-
riotomy, and upsizing the sheath only when nec-
essary all help to maintain the arteriotomy. If
the initial puncture site is poorly placed and the
patient requires a larger access for intervention, it
is safer to obtain access in another location than
to risk bleeding or thrombosis at the puncture site.
A damaged sheath tip may injure the artery at the
access site. During sheath placement, if the tip of
the sheath is damaged, crinkled, or accordioned by
a poorly prepared tract, a fresh sheath should be
placed aer the arteriotomy has been better pre-
pared. During the procedure, inating a balloon in
the end of the sheath should be avoided. An angio-
plasty balloon should be fully deated before with-
drawing it into the sheath.
Ensure that the patient is comfortable prior
to pulling the sheath. Catheterize the bladder if
needed. Avoid agitation and discomfort due to
bladder distension aer the diuresis caused by con-
trast administration. Some patients are uncom-
fortable aer lying on the angio table because of
back or limb pain. ese patients may need a short
break or additional sedation. If blood pressure is
elevated, it can make hemostasis more dicult
to achieve. Consider antihypertensive medica-
tion. If a signicant amount of heparin has been
administered, measure the activated clotting time
(ACT) and wait to remove the sheath until it is 180
seconds or less. Administer additional local anes-
thetic at the access site if the procedure has gone on
for more than 1 hour.
HOLDING PRESSURE
When the plan is to hold pressure, the hemostatic
access sheath is removed in the recovery room
rather than in the operating room. e patient is
placed in the supine position. If there is a large pan-
nus, an assistant retracts the skin fold to achieve
a horizontal working surface. Pressure is applied
before the catheter or sheath is removed. e few-
est number of gauze pads possible are used (usually
just one is best) to hold pressure so that the pulse is
readily palpable while holding pressure. If pressure
is applied in the correct location, there should be
minimal bleeding.
Following a retrograde femoral artery punc-
ture, digital pressure is held at the location of
the arteriotomy proximal to the skin punc-
ture site (Figure 30.1). The tract leading from
the skin to the arteriotomy is also compressed.
However, no amount of tract compression is of
value if the arteriotomy is not adequately com-
pressed. The ipsilateral foot is exposed while
pressure is held so that the color of the foot can
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428 Puncture site management
be continuously assessed. The goal is to pre-
vent bleeding from the artery while maintain-
ing flow through it and permitting a platelet
plug to form on the flow surface. Applying too
much pressure occludes the artery while too
little pressure applied in the wrong place allows
continued hemorrhage or may even promote
it. Applying pressure to the artery distal to the
puncture site increases resistance, which forces
more extravasation.
Antegrade femoral artery puncture requires a
two-handed technique. One hand is placed proxi-
mal to the inguinal ligament to apply pressure over
the distal external iliac artery in order to decrease
the head of pressure owing through the punctured
segment and to diminish any oozing into the ret-
roperitoneal space (Figure 30.2). e goal is not to
occlude arterial ow, even temporarily. e other
hand places point pressure over the area of arte-
rial puncture just distal to the inguinal ligament
A
B
C
D
E
Fig. 30.1 Puncture site management. (A) A percutaneous catheter is placed. (B) Pressure is held at
the arteriotomy site after the catheter is removed. (C) Digital pressure does not occlude the flow.
Platelets deposit at the arteriotomy site as digital pressure prevents leakage of blood from the artery.
(D) The ipsilateral foot is exposed during pressure application to continuously evaluate the color of
the foot. (E) Even if greater pressure is required for hemostasis, flow is not occluded.
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Closure devices 429
and over the arteriotomy. e distal hand can also
assess the pulse and ensure that the pressure exerted
by the proximal hand is not signicant enough to
stop ow. Pressure is usually held for a minimum of
15minutes. Patients who are on antiplatelet agents
or hypertensives or who have larger arteriotomy
sizes (>7-Fr) probably need to be compressed for
longer. Managing the puncture site is a routine task,
but doing it improperly guarantees a complication.
erefore, stay actively involved and do not delegate
this task completely to someone else.
TIMING THE SHEATH REMOVAL
e sheath is usually removed at completion of the
procedure unless heparin has been administered.
An ACT may be useful to help time sheath removal.
If the sheath is to remain in place for more than
1 hour, consider a low-dose heparin drip through
the side arm of the sheath. If the access site is to be
handled with a closure device, this is done on the
table at the conclusion of the procedure regardless
of whether the patient is anticoagulated.
CLOSURE DEVICES
Many practices have evolved to a point where
the preferred method for all patients undergoing
femoral access is to use closure devices. e advan-
tages of closure devices are signicant. ey allow
for early ambulation and discharge of the patient.
roughput of patients in the procedure area is
important, especially in the outpatient setting. e
patient also avoids the experience of having some-
one pressing on the groin. Many patients have
back or joint problems that are exacerbated by a
prolonged period in the supine position. Closure
devices are better at achieving hemostasis for larger
sheaths (>7-Fr). Closure devices can be used while
the patient is still anticoagulated, without waiting
until a later time to manage the sheath. Asexperi-
ence has increased over time, closure devices have
become more widely used and most operators have
developed a workow that takes these devices into
account. Increasing experience levels and better
patient selection have also helped to decrease com-
plication rates.
Challenges with closure devices include cost,
occasional acute failure to close the arteriotomy,
and rare but devastating complications such as
local infection or distal embolization. Closure
devices are only approved for femoral access.
e instructions for use should be followed when
selecting patients in which to use these devices.
e main reason not to use a closure device is
because of some technical or anatomic issue that
precludes its use. A severely diseased, calcied,
or stenotic femoral artery is the most common
reason. If the puncture site is low, at the femoral
bifurcation, or in the profunda femoris or super-
cial femoral artery (SFA), it is usually better to
hold the access site manually than to use a closure
device. When a treatment site, such as the distal
end of an external iliac artery stent, is close to the
puncture site, there is a risk that the device will
catch on the stent. Much of this can be obviated
by using ultrasound guidance to choose a puncture
site and to guide the needle insertion into the loca-
tion that is most favorable for closure.
ere are two general categories of closure
devices: those that place a stitch (e.g., Perclose
ProGlide
™
, Figure 30.3) or rivet (e.g., Prostar
®
,
Figure 30.4) and those that place a collagen plug
(e.g., Angio-seal or Exo-seal, Figures 30.5a nd30.6).
A
B
Fig. 30.2 Hemostasis after antegrade puncture.
(A) An antegrade catheter is placed. (B) After
the catheter is removed, pressure is applied both
above and below the inguinal ligament.
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430 Puncture site management
BA
D E F
C
G
Fig. 30.3 Suture-mediated closure device. (A)ThePerclose ProGlide™ is featured in Chapter28,
Fig u r e 28 .1, in the section on large vessel closure. A side view of an artery requiring closure is dem-
onstrated. (B) The closure device is advanced until the guidewire port reaches the skin level and the
wire is then removed. (C) The closure device catheter is advanced until there is backbleeding from
the side port. This indicates that the sutures are at the level of the artery. (D) The lever on the side is
pushed upward to deploy the foot plates. (E) The plunger is depressed to deploy the sutures. (F) The
lever is released to gather up the foot plates and the closure catheter is removed. (G) On removal
of the catheter the knot pusher is used to push the knot to the artery along the blue-tipped suture,
which remains under tension, and subsequently the white-tipped suture is also placed on tension to
set the knot.
A CB
Fig. 30.4 Clip on the outside of the vessel. (A) The closure device is inserted into the artery. It is
adjusted so that the tip is just inside the vessel. (B) The clip is placed, gathering up adventitia on the
outside of the vessel. (C) The closure device is removed and pressure held for a few minutes.
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Closure devices 431
ere are more examples of each of these types of
closure devices than those mentioned here. Both of
the types described here have been widely adopted
and have acceptably low complication rates. Most
accomplished operators are experienced with and
regularly use at least one and sometimes two devices
in each of these categories. Common to the use of
all closure devices is the advantage of ultrasound
guidance and the need for a very meticulously kept
sterile technique.
Each type of device has its nuances and each is
being continually rened. Suture-mediated clo-
sure is warranted for large bore access closure.
is includes sheath access >10-Fr. At 12-Fr, two
suture-mediated closure catheters are used, as
described in Chapter 28. e skin incision must
be enlarged a little if a smaller caliber sheath
is used (i.e., 6-Fr or less). e reason for this is
to have a clear and open path for the knot to be
delivered to the anterior wall of the artery. e
sutures are monolament and they must be wet
to slide on themselves. Traction on the second-
ary suture prematurely (with the white tip) will
set the knot being delivered and hemostasis will
be poor. Suture-mediated closure requires the
catheter to be advanced without guidewire guid-
ance for a portion of its insertion. Most of the time,
this is not consequential. However, if the patient
A B
C D
Fig. 30.6 Collagen plug on the outside of the vessel. (A) The sheath is advanced until backbleeding
is achieved. (B) A small balloon is inflated to fill the space and prevent backbleeding from the artery.
(C)A collagen plug is placed and allowed to form. (D) The balloon is deflated and removed and pres-
sure is held for a few minutes.
A CB
Fig. 30.5 Collagen plug-mediated closure device. (A) The sheath is advanced until the tip of the sheath
is inside the artery and backbleeding is seen through a side port. (B) The collagen plug is loaded into
the sheath and pushed to its tip. (C) After the disc is inside the artery, the sheath is removed. By putting
traction on the sheath, the collagen plug is brought down to the artery. After the collagen plug is in
place and tension held for a few seconds, the suture may be divided below the skin level.
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432 Puncture site management
has undergone an iliac artery reconstruction or
the arteries are diseased or severely tortuous, this
maneuver may not be possible. In severely calci-
ed arteries the needle that delivers the suture may
not penetrate the artery. Aer the guidewire is
removed, any breakage of the suture or other fail-
ure means that closure is not possible, except by
manual pressure or open repair. In patients with
a hostile common femoral artery and a reason-
ably large diameter proximal SFA, the proximal
SFA may be considered for access, although this is
not a labeled usage for the device. Placement of a
suture-mediated closure device too far proximally
along the common femoral artery may result in the
device going through the inguinal ligament. is is
typically painful and may cause the device to fail
when the patient gets up to ambulate.
Collagen plug-mediated closure devices deliver
a collagen plug to the anterior surface of the artery.
e collagen plug may ll the entire tract from the
skin puncture to the artery to varying degrees.
Collagen is more susceptible to the possibility of
infection. e collagen plug may be delivered as
part of a sandwich, with a small disc on the inside
of the artery anchored to a small plug on the out-
side of the artery. e collagen plug may also be
delivered only to the outside of the artery and
expand to ll a large portion of the tract and help
to secure its position in that manner. Ultrasound
guidance is useful in placing the needle puncture
at the least diseased location and on the anterior
surface of the common femoral artery. A collagen
plug may fail if the artery is punctured on its side.
A collagen puncture may also fail if it is placed
through the inguinal ligament. When the patient
ambulates, the plug will likely move and cause
sudden hemorrhage. Collagen plugs are useful for
sheaths up to about 8-Fr. Larger arteriotomies are
not as securely managed using this technique.
A major challenge occurs when the puncture
is located near an occlusive lesion in the common
femoral artery. is is typically identied using an
oblique femoral arteriogram. Proceeding with clo-
sure is typically outside the instructions for use.
MANAGING PUNCTURE SITE
COMPLICATIONS
Several factors contribute to percutaneous femoral
artery puncture site hemorrhage: anticoagulation
or bleeding disorders; presence of severe common
femoral artery calcication; high puncture, involv-
ing the distal external iliac artery; low puncture,
involving the crotch of the femoral bifurcation or
proximal deep femoral artery; a puncture site that
lacerates the side of the artery; or a large caliber
arteriotomy (especially 10-Fr or larger). Puncture
site management is oen relegated to a member of
the team with the least experience or understand-
ing of the procedure performed. However, manag-
ing a complication aer it has occurred requires
more energy and expertise than is needed when
the puncture site is managed well to begin with.
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433
Selected reading
PART I
AbuRahma AF, Elmore M, Deel J et al. (2007)
Complications of diagnostic arteriography
performed by a vascular surgeon in a recent
series of 558 patients. Vascular 15(2):9 2–7.
Fujihara M, Haramitsu Y, Ohshimo K et al. (2017)
Appropriate hemostasis by routine use of
ultrasound echo-guided transfemoral access
and vascular closure devices after lower
extremity percutaneous revascularization.
Cardiovasc Interv Ther 32(3):233– 40.
Geschwind J (2013) Abram’s Angiography.
Lippincott, Williams & Wilkins, Philadelphia.
Jahnke T, Schäfer JP, Bolte H et al. (2008)
Retrospective study of rapid-exchange mono-
rail versus over-the-wire technique for femo-
ropopliteal angioplasty. Cardiovasc Intervent
Radiol 31(5):854–9.
Kim D (2017) Vascular Imaging and Endovascular
Interventions. Jaypee Brothers Medical
Publishers, London.
Lonn L, Edmond JJ, Marco J, Kearney PP,
Gallagher AG (2012) Virtual reality simula-
tion training in a high–fidelity procedure
suite: operator appraisal. J Vasc Interv Radiol
23(10):1361–6.
Madden NJ, Calligaro KD, Zheng H et al. (2019)
Outcomes of brachial artery access for endo-
vascular interventions. Ann Vasc Surg 56:81– 6.
Montero-Baker M, Schmidt A, Bräunlich S et
al. (2008) Retrograde approach for com-
plex popliteal and tibioperoneal occlusions.
JEndovasc Ther 15(5):594–604.
Osborn AG (1999) Diagnostic Cerebral
Angiography. Wolters Kluwer Health,
Philadelphia.
Schroeder J (2013) Peripheral Vascular
Interventions: An Illustrated Manual. Thieme,
Stuttgart.
Seldinger S (1953) Catheter replacement of the
needle in percutaneous arteriography. Acta
Radiol 39:368–76.
Sobolev M, Slovut DP, Lee Chang A et al. (2015)
Ultrasound-guided catheterization of the
femoral artery: A systematic review and
meta-analysis of randomized controlled trials.
JInvasive Cardiol 27(7):318–23.
Vatakencherry G, Gandhi R, Molloy C (2016)
Endovascular access for challenging anato-
mies in peripheral vascular interventions.
TechVasc Interv Radiol 19(2):113 –2 2 .
Walker C (2013) Guidewire selection for periph-
eral vascular interventions: Understanding the
design elements of interventional guidewires
is the basis for successful use. Endovascular
Today May 2013.
Zia S, Singh K, Juneja A et al. (2018) Safety and
feasibility of transradial access for noncoro-
nary and peripheral vascular interventions.
Ann Vasc Surg 53:2 55 – 61.
PART II
Banerjee S, Thomas R, Sarode K et al. (2014)
Crossing of infrainguinal peripheral arte-
rial chronic total occlusion with a blunt
microdissection catheter. J Invasive Cardiol
26(8):363 – 9.
Bausback Y, Wittig T, Schmidt A et al. (2019)
Drug-eluting stent versus drug-coated bal-
loon revascularization in patients with femoro-
popliteal arterial disease. J Am Coll Cardiol
73(6):667–79.
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