IS Case 317: Residual collagen plug from an arteriotomy closure device

Jacinto Camarena III, MD


Imaging Sciences URMC 2009
Publication Date: 2009-09-14

History

Patient is a 56-year-old male with a bruit over his right groin access site, status post-percutaneous coronary intervention one month prior. Ultrasonography was requested to evaluate for possible pseudoaneurysm.

Findings

There is a 0.9 x 0.8 x 0.4 cm circumscribed hypoechoic region abutting the external aspect of the anterior wall of the right common femoral artery just superior to the bifurcation (Fig. 1). Color Doppler interrogation does not demonstrate a neck connecting this collection with the femoral artery (Fig. 2) nor does spectral Doppler show the "to and fro" pattern that is characteristic of a pseudoaneurysm.

Diagnosis

Residual collagen plug from an arteriotomy closure device

Discussion

Arteriotomy closure devices are used with increasing frequency by interventionalists for rapid hemostasis allowing patients to ambulate sooner after percutaneous vascular access. Various types have been developed including those that utilize sealant or pro-coagulant plugs, as well as, suture mediated or clip/staple deploying devices.

In the above case, the patient’s nurse confirmed that Angio-Seal™ (St. Jude Medical, St. Paul, MN) was utilized after percutaneous coronary intervention one month prior to the current ultrasound evaluation. This device “sandwiches” the arteriotomy site between bioabsorbable components including an extraluminal collagen plug and an intraluminal polymer anchor with the aid of a self-tightening suture. Corkill et al. [1] demonstrated that soon after deployment the collagen plug is difficult to appreciate, as it is isoechoic compared to the echogenic perivascular tissues. After 48 hours, the intraluminal echogenic anchor is revealed, as the acoustic shadowing believed to be created by air trapped within the collagen plug microfibers subsides. Although the manufacturer maintains that all components are absorbed by 90 days, one study has shown that the collagen plug may still be visualized as a hypoechoic collection even three months post intervention [2].

Complications after Angio-Seal™ deployment have been reported in up to 2% of patients [3]. Examples that may be seen at ultrasonography include vessel occlusion due to internalization of the pro-coagulant plug, dissection/disruption of atherosclerotic plaques in patients with peripheral vascular disease, or anchor embolus.

References

  1. Corkill RA, Hughes PM, Elford JC, Roobottom CA. The in vitro and in vivo ultrasonographic appearances of the angio-seal percutaneous closure device. Clin Radiol. 2002 Oct;57(10):930-6. PMID: 12413919
  2. Blanc R, Mounayer C, Piotin M, Sadik JC, Spelle L, Moret J. Hemostatic closure device after carotid puncture for stent and coil placement in an intracranial aneurysm: technical note. AJNR Am J Neuroradiol. 2002 Jun-Jul;23(6):978-81. PMID: 12063228
  3. Abando A, Hood D, Weaver F, Katz S. The use of the Angioseal device for femoral artery closure. J Vasc Surg. 2004 Aug;40(2):287-90. PMID: 15297822

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