Sequential retroperitoneal venous hemorrhage and embolism of an angio-sealpuncture closure device complicating iliac artery angioplasty

Purpose: To present a case of iatrogenic puncture closure device embolizati on complicating surgery for retroperitoneal hemorrhage (RPH) secondary to a ngioplasty-induced common iliac vein trauma. Methods and Results: A 78-year-old woman with rest pain underwent successfu l kissing balloon dilation of her aortoiliac bifurcatian for a calcified os tial stenosis of the left common iliac artery. Hemostatic puncture closure devices (Angio-Seal) were used to secure both femoral punctures. A right-si ded retroperitoneal hematoma developed, and during surgical exploration of the right groin, the Angio-Seal device was removed. The only bleeding site found was the external iliac artery puncture and it was repaired. She again became hypovolemic 18 hours later and was returned to surgery, where bilat eral groin explorations and laparotomy by the vascular surgical team found a tear in the left common iliac vein. After repair, the patient was stable for 48 hours when the left leg became critically ischemic. Angiography dete cted a new high-grade stenosis in the left profunda femoris artery; embolec tomy retrieved a footplate from the left puncture closure device-The patien t died 11 days later from multiorgan failure. Conclusions: RPH should be considered early as an occult cause of hypovolem ic shock developing soon after even technically straightforward iliac angio plasty. Interventionists should be aware that using the Angio-Seal device r isks acute limb ischemia if footplate embolization occurs.