Before the introduction of VCDs in the 1990s, the benchmark for vascular access-site control was manual compression. VCD are classified into three major categories; plug-based, suture-mediated, and clip-based (Bechara et al. 2010).The use of VCDs have been favoured over manual compression because of their capacity to reduce the time to hemostasis and promote early patient mobilization (Bechara et al. 2010; Bangalore et al. 2009). However, the safety and efficacy of these devices, has come under scrutiny due to their reported association with vascular access-site complications including infection, bleeding and limb ischemia (Biancari et al. 2010; Bechara et al. 2010; Bangalore et al. 2009).
The incidence of such vascular complications has been found to be higher in cases of device failure (Bangalore et al. 2009). Bangalore et al. reports that device failure is significantly associated with elderly patients and those suffering from diabetes or peripheral artery disease (Bangalore et al. 2009). Additionally, suture-mediated VCDs in particular are reported to be associated with a higher risk of failure compared to other types of devices (Bangalore et al. 2009). On the other hand, ischemic complications have been found to be more common in devices which employ an intraluminal component such as Celt ACD® and Angio-Seal® (St. Jude Medical, Inc., St. Paul, Minn). This is due to the higher risk of distal embolisation of the intraluminal component (Suri et al. 2015).
The Celt ACD® is a novel stainless steel VCD with both intraluminal and extraluminal components. It has several potential advantages over other VCDs including a reduced time to hemostasis and a faster deployment utilising the existing procedural sheath (Jan et al. 2013). Its distinctive metallic structure renders it fluoroscopically detectable, aiding in precise localization of the device in cases of mal-deployment. In addition, Celt ACD® can be utilized in narrower vessels due to its smaller size compared to other VCDs (Jan et al. 2013). When compared to Angio-Seal® in particular, Celt ACD® has demonstrated lower patient discomfort and a reduced incidence of late minor bruising (Cahill et al. 2014).
However, the sharp edges of the intraluminal component might cause serious intimal injury and consequent thrombus formation in the event of distal embolisation of VCDs. In cases of distal embolisation of VCDs, open surgical embolectomies have conventionally been carried out to retrieve the mal-deployed device (Prabhudesai and Khan 2000; van der Steeg et al. 2009). However, cases of successful retrieval of embolised Angio-Seal® devices through endovascular approaches have been reported (Suri et al. 2015; Jud et al. 2017). The successful endovascular retrieval of a distally embolised Celt ACD®, following primary device failure, was reported by Cahill et al. (Cahill et al. 2013). The device was visualised fluoroscopically and found to be situated in the common femoral artery. In order to avoid the subsequent consequences of vessel occlusion, the embolised device was retrieved through an endovascular approach using a triple-looped EN snare (Merit Medical, South Jordan, UT).
In our case, the Celt ACD® embolised to a more distal location and was found to be situated in the TPT. Endovascular retrieval was attempted utilising a snare but this was unsuccessful due to the small diameter of the target artery. Moreover, endovascular manipulation and intimal injury caused by the device led to subsequent thrombosis. Consequently, open surgical exploration led to the successful retrieval of the mal-deployed device.
