PseuSeal technique: endovascular repair of Iatrogenic pseudoaneurysm using ExoSeal.

Abstract

Introduction: The ExoSeal^® (Cordis, Florida, USA) is a bioabsorbable vascular closure device that facilitates hemostasis by deploying a polyglycolic acid (PGA) plug. This report presents the "PseuSeal technique," a novel approach to seal pseudoaneurysm using ExoSeal in an off-label manner.

Methods: The PseuSeal technique includes the PseuSeal Snare and PseuSeal Rendezvous, both performed via a contralateral crossover approach. The choice of approach depends on whether a 4-Fr catheter can be advanced into the pseudoaneurysm cavity. If feasible, the PseuSeal Snare is selected; otherwise, the PseuSeal Rendezvous is employed. In the PseuSeal Snare, a snare is deployed from a 4-Fr catheter within the pseudoaneurysm cavity. An 18-gauge needle is then used to retrogradely puncture the snare loop. A 0.035-inch guidewire is passed through the needle lumen, captured by the snare, and externalized. In the PseuSeal Rendezvous, an 18-gauge needle retrogradely punctures the guidewire within the cavity, and the guidewire is advanced into the needle lumen for externalization. After externalizing the guidewire in both approaches, an ExoSeal-specific sheath is inserted over the guidewire through the pseudoaneurysm neck into the main vessel. A balloon is advanced from the crossover sheath into the main trunk to cover the pseudoaneurysm ostium. The ExoSeal system is then inserted through the second sheath. As the ExoSeal's indicator wire is withdrawn, the balloon is inflated to stabilize the indicator wire, ensuring precise deployment of the PGA plug at the pseudoaneurysm neck. Balloon inflation is maintained for 5 minutes, with an additional 5 minutes if necessary. Hemostasis is confirmed by angiography.

Results: The PseuSeal technique was successfully applied in five common femoral artery　pseudoaneurysms, all of which had failed ultrasound-guided compression. Each case was treated using a 6-Fr ExoSeal device, with no complications or recurrences observed during follow-up. Case 1 involved an 87-year-old female who developed a pseudoaneurysm following a peripheral intervention. The PseuSeal Snare achieved hemostasis in 32 minutes. Case 2 involved a 60-year-old male presenting with a pseudoaneurysm after a coronary intervention. The PseuSeal Rendezvous achieved hemostasis in 50 minutes.

Conclusion: The PseuSeal technique provides an effective alternative for pseudoaneurysm closure.