Closure Device Migration: An Unusual Cause of Acute Limb Ischaemia Following a Simple Endovascular Procedure

Abstract

Introduction: Acute limb ischaemia resulting from foreign body embolisation is an infrequent yet critical complication associated with vascular closure devices (VCDs). Despite the widespread use of VCDs, rare complications such as fragment emboli pose unique challenges, necessitating heightened clinical awareness. This case report presents a case of acute limb ischaemia caused by a VCD malfunction following an endovascular procedure.

Report: A 70 year old male who was diagnosed with a severe claudication of the lower extremity (Rutherford III) due to right common iliac stenosis, underwent angioplasty using a FemoSeal (Terumo Ltd., Surrey, UK) to close the right femoral artery access. Two weeks later, the patient presented with acute lower limb ischaemia due to a right popliteal-tibial occlusion. Emergency surgical thrombo-embolectomy was successfully performed from a medial popliteal approach, and the thrombus, which contained a polymer disc from the VCD at its distal end, was completely removed.

Discussion: Despite VCDs being proven safe and efficient, rare complications such as fragment emboli can occur, and physicians should be aware of the possible delayed onset of symptoms. Moreover, the radiolucent nature of the polymer disc in a FemoSeal complicates diagnostic imaging. While endovascular approaches exist, open surgery is a safe and effective strategy for retrieving fragments and treating the patient in acute limb ischaemia cases.

Conclusion: Physicians should remain vigilant for embolic risks associated with vascular closure devices, even with suitable anatomy and following guidelines, especially considering the trend toward early ambulation and discharge.

Keywords: Acute limb ischaemia; FemoSeal; Foreign body embolism; Popliteal artery; Tibioperoneal trunk; Vascular closure device.

Figure 1

Pre-operative computed tomography angiogram images. (A) Multiplanar reconstruction showing the popliteal artery, tibioperoneal trunk, and posterior tibial artery. (B) Three dimensional reconstruction of the popliteotibial region, indicating incomplete occlusion of the distal popliteal artery and complete occlusion of the tibioperoneal trunk.

Figure 2

Peri-operative photograph demonstrating the polymer disk and suture removed during thrombo-embolectomy.