1. 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

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

3. 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

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

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

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

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

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

9. 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

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

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

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

13. Contralateral access and femoral angiogram reveals femoral perforation

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

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

16. 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

17. Repeat angiogram residual thrombus in CFA and anterior tibial arteries

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

19. 4 mg intra arterial tPA administered through the catheter below the level of the knee – 10 minutes later c/o discomfort in left groin

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

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

22. 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.

23. 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