Infected Pseudoaneurysm Associated With Umbilical Depression at the Puncture Site Due to Perclose ProStyle Suture®: Restoration for Infection Prevention.

Percutaneous coronary intervention is now commonly performed using the transradial artery approach, but endovascular therapy (EVT) is still often performed via the femoral artery (FA). Vascular closure devices have been developed and are commonly used to achieve hemostasis at the FA puncture site. However, there have been some reports of infection complications associated with the use of vascular closure devices. When Perclose ProStyle Suture® (Abbott, Abbott Park, IL, USA) is used for hemostasis in thin patients, the puncture site may become umbilical depressed. We report three cases of umbilical puncture site depression with the Perclose ProStyle Suture®. Case 1 was a 78-year-old male with a body mass index (BMI) of 18 kg/m and a thin build who underwent EVT for peripheral arterial disease with rest pain. Stents were implanted in the stenosis of both external iliac arteries and the occluded lesion of the right superficial femoral artery (SFA) via the left FA approach. The puncture site was sutured with Perclose ProStyle Suture®, but the puncture site became depressed like a navel. One month later, he visited the hospital with pus discharge from the left FA puncture site, and one week later, he visited the hospital with bleeding from an infected pseudoaneurysm. Although vascular repair surgery was performed, it recurred a month later, and thus the infected tissue was debrided and vascularization was performed using a bovine pericardial patch. Case 2 was an 88-year-old female with a BMI of 18 kg/m who was thin and had intermittent claudication. EVT was performed on the occluded lesion in the left SFA. A stent was implanted in the left SFA via the right FA, and the puncture site was hemostatized with Perclose ProStyle Suture®. Two weeks later, she was referred to our institution because of bleeding from the puncture site in her right FA, and a contrast computed tomography revealed an infected pseudoaneurysm. She was referred to vascular surgery, where the infected area was debrided and vascular repair surgery was performed. Case 3 was a 72-year-old male (BMI 18.4 kg/m) with intermittent claudication. EVT was performed for a severe stenosis lesion in the right SFA. A stent was implanted in the right SFA via the left FA approach, and the puncture site was hemostatized using Perclose ProStyle Suture®. The puncture site then became depressed like a navel. Based on the experience of cases 1 and 2, the subcutaneous tissue around the suture was incised, the suture was buried in the subcutaneous tissue, and the dermis was sutured with 5-0 absorbable sutures. The patient is being followed up as an outpatient, and there is no evidence of infection, and the condition is good. Due to the design of the device, the Perclose ProStyle Suture® is designed to suture approximately 1 cm proximal to the vessel wall. Therefore, in such cases, where the patient is thin and has thin subcutaneous tissue, the suture is placed close to the dermis, and when ligated, the dermis is depressed like a navel. When the suture is close to the dermis, the risk of vascular infection increases; therefore, it is preferable to perform the repair so that the suture is buried in the subcutaneous tissue.