Rotational Atherectomy for Treating Arterial Access-Site Stenosis Caused by Vascular Closure Device Failure Following Transcatheter Aortic Valve Replacement
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J INVASIVE CARDIOL 2024. doi:10.25270/jic/24.00273. Epub October 8, 2024.
Suture-mediated vascular closure devices (VCD) are used to seal large-bore arterial access sites following transcatheter aortic valve replacement (TAVR). VCD failure usually results in hemorrhage but may cause arterial stenosis in rare cases. Revascularization may be achieved by balloon dilation or surgical vascular repair. We describe 2 patients with arterial stenosis that was resistant to balloon dilation who were treated with rotational atherectomy.
Case 1
An 88-year-old man with severe symptomatic aortic stenosis (AS), renal failure, and peripheral vascular disease underwent transaxillary TAVR. A 14-French (Fr) sheath was used for the procedure. Following sheath removal, the patient developed a critical stenosis at the access site in the left axillary artery, caused by the sutures of the Perclose ProStyle VCD (Abbott) (Figure 1, Video 1). Balloon dilation failed to dilate the stenosis. The occlusive sutures were ablated using rotational atherectomy via transfemoral access using a 2.0-mm burr (Video 2). Subsequently, an 8 x 60-mm Fluency stent graft (BD) was implanted, and blood flow was restored (Video 3).
Case 2
An 84-year-old woman with severe symptomatic AS, renal failure, and recent left-main coronary stenting was referred for TAVR. A 14-Fr sheath was used for the procedure. The access site in the left femoral artery was sealed using a Perclose Prostyle VCD. Angiography revealed critical stenosis at the access site, which could not be dilated with a balloon (Figure 2, Video 4). Rotational atherectomy via transbrachial access using a 2.0-mm burr ablated the occlusive sutures (Video 5) and enabled implantation of a 6 x 40-mm Fluency stent graft (BD) (Video 6).
In both cases, the VCD-induced arterial stenosis was resistant to balloon dilation and the sutures were successfully ablated using rotational atherectomy, facilitating stent graft deployment. This strategy was facilitated by our practice of leaving an 0.014-inch “safety” wire across the access site for treating vascular complications when necessary.
Affiliations and Disclosures
Hussein Sliman, MD; Amnon Eitan, MD; Ofer Galili, MD; Keren Zissman, MD; Ronen Jaffe, MD
From the Department of Cardiology, Lady Davis Carmel Medical Center, Haifa, Israel; and Technion Israel Institute of Technology, Haifa, Israel.
Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.
Consent statement: The authors confirm that informed consent was obtained from the patients for the study and interventions described in the manuscript and to the publication of their data.
Address for correspondence: Ronen Jaffe, MD, Department of Cardiovascular Medicine, Lady Davis Carmel Medical Center, 7 Michal St, Haifa 34362, Israel. Email: jaffe@clalit.org.il, jafferonen@gmail.com
