Clinical Images

“Avulsion Injury” of the Artery by a Suture-Mediated Closure System During Transcatheter Aortic Valve Implantation

Toshiki Kaihara, MD, PhD; Takumi Higuma, MD, PhD; Shingo Kuwata, MD, PhD; Masashi Koga, MD; Mika Watanabe, MD; Kazuaki Okuyama, MD; Ryo Kamijima, MD, PhD; Masaki Izumo, MD, PhD; Yuki Ishibashi, MD, PhD; Yasuhiro Tanabe, MD, PhD; Yoshihiro J. Akashi, MD, PhD

Toshiki Kaihara, MD, PhD; Takumi Higuma, MD, PhD; Shingo Kuwata, MD, PhD; Masashi Koga, MD; Mika Watanabe, MD; Kazuaki Okuyama, MD; Ryo Kamijima, MD, PhD; Masaki Izumo, MD, PhD; Yuki Ishibashi, MD, PhD; Yasuhiro Tanabe, MD, PhD; Yoshihiro J. Akashi, MD, PhD

J INVASIVE CARDIOL 2020;32(7):E193.

Key words: suture-mediated closure system, transcatheter aortic valve implantation, vascular complication


An 84-year-old woman with severe aortic stenosis underwent transcatheter aortic valve implantation (TAVI). Although preprocedural computed tomography revealed a calcification of the common femoral artery, the calcification did not involve the whole arterial circumference. Therefore, we used the Perclose ProGlide suture-mediated closure system (Abbott Vascular) to deliver a single suture to close the access site in her common femoral artery following the TAVI procedure. 

We inserted a 14 Fr eSheath introducer sheath set (Edwards Lifesciences) and performed TAVI. Before removing the sheath, we advanced the knot with a knot pusher and pulled on the suture limb to close the access site. However, the knot and a circular cross section of the interior arterial wall were removed together from her body (Figure 1). We immediately delivered manual compression to the site and performed percutaneous long balloon inflation to stop the bleeding. Surgery was not required, and she spent the usual period of hospitalization for TAVI.

There have been no reports about such “avulsion injury” of the femoral artery with a suture-mediated closure system during TAVI. Our pathological analysis of the specimen revealed that it consisted of mainly intima of the blood vessels. Although there was no calcification at the puncture site, calcification was present around the site. This calcification might have cracked and injured the intima, resulting in the complication. We should consider the cut-down method in cases with calcification restricted to the region surrounding the puncture site when we perform TAVI in patients with severe aortic stenosis.


From the Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no conflicts of interest regarding the content herein. 

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted November 1, 2019.

Address for correspondence: Dr Toshiki Kaihara, Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, 2-16-1 Sugao, Miyamae, Kawasaki, Japan. Email: m03014tk@jichi.ac.jp

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