Bhalaghuru Chokkalingam Mani MD To coagulate or anticoagulate? Management Dilemma during complex popliteal aneurysm intervention complicated by femoral arterial perforation and acute thrombosis of left SFA Bhalaghuru Chokkalingam Mani MD Andrew Goldsweig MD Omar Hyder MD Warren Alpert School of Medicine of Brown University

Bhalaghuru Chokkalingam Mani, M.D., I have no relevant financial relationships

Learning objectives Utility of ultrasound and fluoroscopic guided access of femoral arteries. Utility of fluoroscopic monitoring during large bore sheath exchange Management decision in setting of large vessel bleeding and acute leg ischemia simultaneously

Clinical Presentation 71 YO M w HTN, HL, non healing left foot ulcer found to have partially thrombosed large left popliteal artery aneurysm

Initial attempt at intervention from contralateral access - extremely tortuous bilateral common and external iliac arteries with a acute aorto-iliac bifurcation angle

Extremely difficult maneuvering required to navigate the 6 Fr Morph access pro to the other side

IVUS revealing size of aneurysm to be 10 mm in average size requiring 10 mm covered stents and at least 11 Fr sheath

Plan to repeat procedure with antegrade access and use covered stents for popliteal aneurysm

Repeat attempt at intervention Pre close sutures placed 11 Fr sheath placed Difficulty drawing back and advancing stent over sheath revealed sheath was bent with an acute angle Exchanged for a new 11 Fr sheath

After 2nd 11 Fr sheath placement – still very angulated secondary to body habitus

Able to successfully place covered PTFE Viabahn stents to exclude the popliteal aneurysm

After popliteal stents were placed Atrial fibrillation with RVR and low BP Expanding left groin and scrotum

Contralateral access and femoral angiogram reveals femoral perforation

Balloon tamponade and angiogram post, reveals sluggish flow in the femoral artery and filling defect consistent with thrombus

Management options? Mechanical thrombectomy Catheter directed thrombolytic Anticoagulation Call the surgeon All of the above

Management Overnight systemic anticoagulation with heparin Initially distal pulses present by Doppler only Vascular surgery consulted Return of 2+ palpable DP and PT by morning Repeat angiography the next day

Repeat angiogram residual thrombus in CFA and anterior tibial arteries

s/p angiojet of SFA, anterior tibial arteries showed residual thrombus

4 mg intra arterial tPA administered through the catheter below the level of the knee – 10 minutes later c/o discomfort in left groin

Management options? Protamine and reverse anticoagulation Balloon tamponade Call the surgeon

Vascular surgery recommendation was to perform covered stent vs surgery elected to perform prolonged balloon inflations with achievement of hemostasis

Hospital course Continued DAPT without anticoagulation Atrial fibrillation with RVR again the next day Brief episode of hemodynamic instability requiring intubation and pressors for less than a day CTA revealed groin and scrotal hematoma but no RP bleeding Subsequently extubated, off pressors and stabilized.

Take Home Messages CTA pre procedure with runoff would have helped define anatomy Fluoroscopic guidance during sheath exchange can prevent precarious sheath manipulation and avoid sheath rupture and arterial perforation Recognition that initial discomfort and mild hypotension was a harbinger of occult bleeding and look harder to rule out bleeding Catheter directed low dose tPA even after hemostasis resulted in systemic fibrinolytic state causing rebleeding