Diagnostic Value of Femoral Vein Flow Pattern for Detecting Incidental Valve Ligation by Suture-Mediated Closure Device

An 85-year-old man underwent a 2nd catheter ablation for recurrent atrial fibrillation. An 8.5F SL0 (Jude Medical) and 8.5F VIZIGO sheath (Biosense Webster) were placed in the right common femoral vein (CFV) using ultrasonography-guided venous puncture. The vessel was closed with a single suture using a preclose technique with the Perclose ProGlide suture-mediated closure System (Abbott). The disappearance of backflow through the marker lumen was confirmed, and immediate hemostasis was achieved after ligation using a suture knot. Real-time assessment of anterior wall traction while pulling back on the suture knots ruled out posterior wall ligation. Ultrasonography on postprocedural day 1 revealed no venous narrowing. However, the femoral venous flow, which had shown a phasic flow pattern at 3 months preprocedure, demonstrated a continuous, flat low flow without respiratory changes indicative of a proximal site obstruction (Figure A,B). On postprocedural day 12, the patient was readmitted with right lower extremity edema (Figure C). Contrast-enhanced computed tomography revealed no severe stenosis; however, venography immediately above the obstruction site confirmed occlusion (Figure D,E). Surgery performed on postprocedural day 16 revealed CFV occlusion due to incidental suturing of the venous valve (Figure F,G). The swelling resolved after surgical repair.

Figure.

Doppler flow pattern of the common femoral vein (CFV) near the puncture site on (A) 1 day postprocedure vs. (B) 3 months preprocedure. (C) Gross appearance of the lower extremities on postprocedural day 12. Circumference of the right and left thigh was 60.5 and 42.5 cm, respectively. (D) Venography and (E) contrast-enhanced computed tomography. Yellow arrow indicates proximal to distal with magnified view. (F) Schematic illustration and (G) intraoperative findings. Direct visualization revealed suturing of the bicuspid CFV valve with threads; both threads and valves were removed.

The femoral venous flow pattern was attributed to incidental valve ligation and it is suggested that operators should check the venous flow pattern before completing the procedure.

Disclosures

The authors declare no conflicts of interest.

IRB Information

Toyama Prefectural Central Hospital Ethics Committee (no. 65-18).