Percutaneous closure using a Perclose ProGlide device for an iatrogenic femoral arteriovenous fistula caused by venoarterial extracorporeal membrane oxygenation insertion: A case report

Percutaneous closure using a Perclose ProGlide device for an iatrogenic femoral arteriovenous fistula caused by venoarterial extracorporeal membrane oxygenation insertion: A case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Percutaneous closure using a Perclose ProGlide device for an iatrogenic femoral arteriovenous fistula caused by venoarterial extracorporeal membrane oxygenation insertion: A case report Hiroki Kuji, Naoki Hayakawa, Hiromi Miwa, Yasuyuki Tsuchida, Shinya Ichihara, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7807167/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 09 Apr, 2026 Read the published version in CVIR Endovascular → Version 1 posted 4 You are reading this latest preprint version Abstract Background: Iatrogenic femoral arteriovenous fistula (AVF) is a representative complication of a percutaneous femoral approach to cannulation. Because open surgical repair is highly invasive, endovascular treatment for AVFs is receiving increasing attention. We report a case of successful percutaneous AVF closure using a Perclose ProGlide closure device. Case presentation: A 56-year-old man underwent percutaneous venoarterial extracorporeal membrane oxygenation decannulation and hemostasis. Final angiography showed an AVF, with a short and wide neck. We directly punctured the fistula with fluoroscopic guidance using a 21-G puncture needle. A 0.014-inch wire was inserted and replaced with a 0.035-inch wire, and the arteriovenous fistula was occluded using the Perclose ProGlide device. We performed additional balloon dilation to occlude blood flow to the AVF from the femoral artery and vein. The shunt flow almost completely disappeared, and complete disappearance of the AVF was confirmed by vascular ultrasound 6 months later. Conclusions: This interventional technique using a Perclose ProGlide devicemay offer a treatment option for iatrogenic AVFs, particularly those with a short and wide neck or those involving the common femoral artery, where conventional techniques may not be suitable Iatrogenic femoral arteriovenous fistula Perclose ProGlide endovascular therapy Figures Figure 1 Figure 2 1. Background Iatrogenic femoral arteriovenous fistula (AVF) is a representative complication of a percutaneous femoral approach to cannulation. The incidence of post cannulation AVF has been reported to be approximately 0.86% [ 1 ]. The presentation of femoral AVFs varies. Most patients present late with chronic limb swelling, high-output cardiac failure, and rarely deep vein thrombosis. Although approximately 30% of such post cannulation iatrogenic femoral AVFs resolve spontaneously, intervention approaches are needed for patients with signs of high-output cardiac failure or limb ischemia [ 1 – 4 ]. The criterion standard for treating AVFs is open surgical repair, but there is a risk of complications, such as groin infection, bleeding, and lymphorrhagia [ 5 ]. Endovascular therapy (EVT), which is a less invasive alternative to surgical treatment, has been developed. EVT for femoral AVFs has also been reported, including endovascular stent grafting and coil embolization [ 6 – 8 ]. Currently, there is no standard of care for endovascular treatment of femoral AVFs, and individualized treatments are required for each case [ 9 ]. Here, we report a case of successful percutaneous femoral AVF closure using a Perclose ProGlide closure device. 2. Case A 56-year-old man presented at our hospital complaining of chest pain. An electrocardiogram showed an ST elevation in II, III, and aVF. He was diagnosed with ST-elevation myocardial infarction and underwent emergency coronary angiography. During the angiography, the patient developed refractory ventricular fibrillation, and venoarterial extracorporeal membrane oxygenation (VA-ECMO) was initiated. A 16.5-Fr arterial cannula was inserted into the right common femoral artery (CFA), and a 21-Fr venous cannula was inserted into the right common femoral vein (CFV). We subsequently performed a percutaneous coronary intervention for right coronary artery occlusion. The next day, he was hemodynamically stable, so the VA-ECMO was decannulated. We usually remove VA-ECMO percutaneously [ 10 ] and approach the arterial cannula via the left radial artery. We removed the cannula by combining intravascular balloon dilation, a Perclose ProGlide closure device, and manual compression (Fig. 1 -A). The venous cannula was removed by suturing and manual compression. Although removing the percutaneous VA-ECMO decannulation and hemostasis were successful, angiography revealed a femoral AVF (Fig. 1 -B, 1 -C). The fistula had a long and wide neck and was considered to have developed when VA-ECMO was inserted. In this case, we thought that a percutaneous closure was better than a surgical approach because the patient had a high surgical risk as a result of the severe myocardial infarction and required dual antiplatelet therapy. First, we dilated an intravascular balloon on the arterial side for 15 minutes to block blood flow to the fistula, but the fistula did not reduce at all. Therefore, we closed the AVF percutaneously using a Perclose ProGlide device (Abbott Vascular). We punctured the AVF directly with a 21-G metal needle (Merit Advance angiography needle; Merit Medical) under fluoroscopic guidance. A 0.014-inch guidewire (Gladius MGES guidewire; Asahi Intec) was inserted from behind the needle, and the guidewire was advanced into the right superficial femoral artery (Fig. 1 -D). A Corsair Armet microcatheter (Asahi Intecc) was inserted into the inner cylinder of the 6-Fr sheath to reduce the gap between the inner sheath and the 0.014-inch wire. The 6-Fr sheath was inserted, and the 0.014-inch wire was replaced with a 0.035-inch Radifocus wire, and we used the Perclose ProGlide device to occlude the AVF (Fig. 1 -E). Subsequently, an intravascular balloon was dilated on both the arterial and venous sides, and manual compression was applied (Fig. 1 -F). Angiography confirmed that the AVF was almost completely occluded (Fig. 1 -G). The subsequent course was good, and the patient was discharged from the hospital. A lower extremity vascular ultrasound performed six months later showed resolution of the AVF (Fig. 2 ). 3. Discussion We demonstrated that percutaneous AVF closure using a Perclose ProGlide device is an option for less invasive treatment of an iatrogenic AVF. The fistula was wide and clearly visible on angiography, so we were able to treat it by directly puncturing the fistula and inserting a Perclose ProGlide device into the femoral artery. If anatomically feasible, it may be possible to puncture the femoral artery, pass the guidewire through the fistula, and insert the Perclose ProGlide device. However, in this case, based on the angiographical findings, it was determined that approaching from the fistula side would make it easier to insert the device. There are several reports of EVT for iatrogenic femoral AVF using a stent graft. Good results have been reported for AVF closure [ 11 ]. By contrast, the need for long-term dual antiplatelet therapy and the risk of in-stent thrombosis are problematic [ 6 ]. Implantation of a stent graft in the CFA carries the risk of compression or kinking due to its superimposition with the hip joint, which may preclude subsequent ipsilateral femoral catheterization. Moreover, lesions at the femoral arterial bifurcation carry the risk of occluding the deep femoral artery after stent-graft placement. Stent-graft placement in the CFA should be avoided because of the risk of deep femoral artery occlusion and the disadvantage of limiting the access route the next time a catheter is needed [ 7 ]. There have been case reports of embolization using a coil or N -butyl-2-cyanoacrylate, but the risk of distal embolization should be considered. In cases where the neck of the arteriovenous fistula is long enough, embolization may be relatively safe, but it may not be suitable for cases with short or large neck [ 8 ]. In the present case, the neck of the AVF was large and located at the CFA, so the previously reported EVT methods were unsuitable. The Perclose ProGlide device is widely used as a vascular closure system. Although no reports have described its use for the closure of a femoral AVF, similar applications have been reported in the treatment of pseudoaneurysms with the device [ 12 , 13 ]. In these cases, the pseudoaneurysm was directly punctured, and a guidewire was passed through the neck of the pseudoaneurysm into the femoral artery, where it was sutured on the arterial wall side. Once access was established, the device was deployed to close the neck of the pseudoaneurysm. Using this procedure, all eight reported pseudoaneurysms were successfully occluded without complications [ 13 ]. This approach requires a wire and closure device to traverse the neck of the pseudoaneurysm; therefore, it is less suitable for cases with a long and tortuous neck. In such situations, embolization techniques may be a more suitable option. Conversely, lesions with a short and wide neck, particularly those in the CFA that are not amenable to embolization or covered stent placement, may benefit from this closure strategy. In this case, the finding was detected during angiography while performing the ECMO removal procedure in the catheterization lab, and the procedure was performed immediately. It may be considered desirable to perform a CT angiogram preoperatively. To evaluate vascular characteristics, the structure of the neck, and relationships with surrounding structures, and to perform the procedure more safely, we hypothesize that similar considerations may apply to the treatment of femoral AVFs. Although our report describes only a single case, it suggests that Perclose ProGlide closure may be a suitable alternative in select cases. Further investigations and the accumulation of case report data are warranted to clarify its role in this setting. This case was concluded with no complications. However, the efficacy and safety of our method remain unknown because of the single case. A much larger study and long-term follow-up are needed to confirm the safety and efficacy of our method. 4. Conclusions This interventional technique using a Perclose ProGlide closure device may offer a feasible treatment option for iatrogenic AVFs, particularly those with a short and wide neck or involving the CFA, where conventional techniques such as embolization or stent-graft placement may not be suitable. Abbreviations AVF, arteriovenous fistula; CFA, common femoral artery; CFV, common femoral vein; EVT, endovascular therapy; (VA-ECMO) venoarterial extracorporeal membrane oxygenation. Declarations Ethics approval and consent to participate All procedures were performed in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. The study was approved by the Institutional Review Board (IRB) of Asahi General Hospital. Consent for publication Written informed consent was obtained from the patient for publication of this case report and any accompanying images. Availability of data and material The datasets generated and/or analyzed during the current study are not publicly available because individual privacy could be compromised but are available from the corresponding author upon reasonable request. Competing interests NH received honoraria from Terumo, Kaneka Medix, Medicos Hirata, Boston Scientific, Medtronic, and Becton, Dickinson and Company. The other authors report no conflicts of interest. Funding No specific grant from any funding agency in the public, commercial, or not-for-profit sectors was received for this report. Authors’ contributions All the authors have read the manuscript and have approved this submission. HK, NH, HM, YT, SI, SH performed the procedures and pre- and post-procedure follow-ups. HK and NH were major contributors in writing the manuscript. KM drafted the manuscript and revised it critically for important intellectual content. SK provided final approval of the submitted manuscript. Acknowledgements We thank Robin James Storer, PhD, from Edanz (https://jp.edanz.com/ac) for editing a draft of this manuscript. References Zilinyi RS, Sethi SS, Parikh MA, Parikh SA. Iatrogenic arteriovenous fistula following femoral access precipitating high-output heart failure. JACC Case Rep. 2021;3:421-4. Kelm M, Perings SM, Jax T, Lauer T, Schoebel FC, Heintzen MP, et al. Incidence and clinical outcome of iatrogenic femoral arteriovenous fistulas implications for risk stratification and treatment. J Am Coll Cardiol. 2002;40:291-7. Jin L, Wang J, Wu C, Shao C, Yu X, Lei W. Femoral arteriovenous fistula associated with leg swelling 6 months after removal of a hemodialysis catheter: a case report. Medicine. 2015;94:e1738. Thavarajan D, Bakran A. Iatrogenic arteriovenous fistula in the groin presenting as cardiac failure. NDT Plus. 2009;2:46-8. San Norberto García EM, González-Fajardo JA, Gutiérrez V, Carrera S, Vaquero C. Femoral pseudoaneurysms post-cardiac catheterization surgically treated: evolution and prognosis. Interact Cardiovasc Thorac Surg. 2009;8:353-7. Onal B, Kosar S, Gumus T, Ilgit ET, Akpek S. Postcatheterization femoral arteriovenous fistulas: endovascular treatment with stent-grafts. Cardiovasc Intervent Radiol. 2004;27:453-8. Thalhammer C, Kirchherr AS, Uhlich F, Waigand J, Gross CM. Postcatheterization pseudoaneurysms and arteriovenous fistulas: repair with percutaneous implantation of endovascular covered stents. Radiology. 2000;214:127-31. Onal B, Ilgit ET, Akpek S, Coskun B. Postcatheterization femoral arteriovenous fistula: endovascular treatment with N -butyl-cyanoacrylate embolization. Cardiovasc Intervent Radiol. 2006;29:276-8. Gooneratne T, Chanaka KAN, Wijeyaratne SM. An unusual case of femoral arteriovenous fistula associated with acute limb ischemia following femoral vein catheterization for hemodialysis. J Vasc Bras. 2022;21:e20210199. Hayakawa N, Tobita K, Kodera S, Ishibashi N, Kasai Y, Arakawa M, et al. An effective method for percutaneous removal of venoarterial extracorporeal membrane oxygenation by a combination of balloon dilatation in endovascular therapy and the Perclose Proglide™ closure device. Ann Vasc Surg. 2021;73:532-7. Rathod JR, Dhomne S, Taori K, Prasad KP, Guha A. Endovascular stent graft for post-traumatic superficial femoral artery pseudoaneurysms with arteriovenous fistula: 6 months follow-up of 2 cases. J Radiol Case Rep. 2011;5:26-34. Inagaki Y, Nakao M, Arashi H, Yamaguchi J. Novel interventional technique for the treatment of an iatrogenic pseudoaneurysm of the brachial artery. J Cardiol Cases. 2021;25:250-3. Ibrahim K, Christoph M, Wunderlich C, Jellinghaus S, Loehn T, Youssef A, et al. A novel interventional method for treating femoral pseudoaneurysms: results from a monocentric experience. EuroIntervention. 2017;13:366-70. Cite Share Download PDF Status: Published Journal Publication published 09 Apr, 2026 Read the published version in CVIR Endovascular → Version 1 posted Reviewers agreed at journal 13 Oct, 2025 Reviewers invited by journal 12 Oct, 2025 Editor assigned by journal 10 Oct, 2025 First submitted to journal 08 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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16:08:48","extension":"html","order_by":12,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":45752,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7807167/v1/2c4e61891043bcd3ddce5b46.html"},{"id":94480512,"identity":"9973eee0-f7c6-4505-b44c-dc70f39c934c","added_by":"auto","created_at":"2025-10-27 16:11:21","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":71114,"visible":true,"origin":"","legend":"\u003cp\u003eAngiographic imaging. \u003cstrong\u003e(A) \u003c/strong\u003eWe performed percutaneous VA-ECMO removal. We punctured the left radial artery to insert the guiding sheath. The guiding sheath was inserted from the left radial artery to the right common iliac artery. A 0.014-inch guidewire was advanced to the right superficial femoral artery. We inserted a 0.035-inch guidewire into the arterial cannula. An antegrade balloon was dilated in the right common iliac artery to block blood flow. Hemostasis was achieved using a Perclose ProGlide device. The antegrade balloon was subsequently moved to the common femoral artery and dilated at the puncture site for intravascular hemostasis. \u003cstrong\u003e(B) (C) \u003c/strong\u003eDigital subtraction angiography showed that complete hemostasis had been achieved, but there was an AVF at the common femoral artery (black arrow). \u003cstrong\u003e(D)\u003c/strong\u003e We punctured the AVF directly with a 21-G metal needle (black arrow)under fluoroscopic guidance. A 0.014-inch guidewire (white arrow) was inserted from behind the needle, and the guidewire was advanced into the right superficial femoral artery. \u003cstrong\u003e(E)\u003c/strong\u003e The 0.014-inch wire was replaced with a 0.035-inch Radifocus wire through a 6-Fr sheath, and we used the Perclose ProGlide closure device to occlude the AVF. \u003cstrong\u003e(F)\u003c/strong\u003eWe dilated an intravascular balloon on both the arterial and the venous sides. \u003cstrong\u003e(G)\u003c/strong\u003eFollow-up angiography showed that the AVF was almost completely occluded.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7807167/v1/5ad1c356accbb8dd5860700a.jpg"},{"id":94489731,"identity":"63172e69-5623-4886-bfe0-9040a1076f08","added_by":"auto","created_at":"2025-10-27 17:05:49","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":101478,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eVascular ultrasound. \u003c/strong\u003eA lower extremity vascular ultrasound performed 6 months after surgery showed the AVF had disappeared.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-7807167/v1/a49c34c9b9229ab98e11dfe9.jpg"},{"id":106809000,"identity":"e372e4df-292f-4e47-8c70-6c74907500d6","added_by":"auto","created_at":"2026-04-13 16:05:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":606463,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7807167/v1/8b2e8f19-765b-4a3a-a6c2-03eb1c5a0a4c.pdf"}],"financialInterests":"","formattedTitle":"Percutaneous closure using a Perclose ProGlide device for an iatrogenic femoral arteriovenous fistula caused by venoarterial extracorporeal membrane oxygenation insertion: A case report","fulltext":[{"header":"1. Background","content":"\u003cp\u003eIatrogenic femoral arteriovenous fistula (AVF) is a representative complication of a percutaneous femoral approach to cannulation. The incidence of post cannulation AVF has been reported to be approximately 0.86% [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe presentation of femoral AVFs varies. Most patients present late with chronic limb swelling, high-output cardiac failure, and rarely deep vein thrombosis. Although approximately 30% of such post cannulation iatrogenic femoral AVFs resolve spontaneously, intervention approaches are needed for patients with signs of high-output cardiac failure or limb ischemia [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The criterion standard for treating AVFs is open surgical repair, but there is a risk of complications, such as groin infection, bleeding, and lymphorrhagia [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Endovascular therapy (EVT), which is a less invasive alternative to surgical treatment, has been developed. EVT for femoral AVFs has also been reported, including endovascular stent grafting and coil embolization [\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eCurrently, there is no standard of care for endovascular treatment of femoral AVFs, and individualized treatments are required for each case [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Here, we report a case of successful percutaneous femoral AVF closure using a Perclose ProGlide closure device.\u003c/p\u003e"},{"header":"2. Case","content":"\u003cp\u003eA 56-year-old man presented at our hospital complaining of chest pain. An electrocardiogram showed an ST elevation in II, III, and aVF. He was diagnosed with ST-elevation myocardial infarction and underwent emergency coronary angiography. During the angiography, the patient developed refractory ventricular fibrillation, and venoarterial extracorporeal membrane oxygenation (VA-ECMO) was initiated.\u003c/p\u003e\u003cp\u003eA 16.5-Fr arterial cannula was inserted into the right common femoral artery (CFA), and a 21-Fr venous cannula was inserted into the right common femoral vein (CFV). We subsequently performed a percutaneous coronary intervention for right coronary artery occlusion. The next day, he was hemodynamically stable, so the VA-ECMO was decannulated. We usually remove VA-ECMO percutaneously [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] and approach the arterial cannula via the left radial artery. We removed the cannula by combining intravascular balloon dilation, a Perclose ProGlide closure device, and manual compression (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e-A). The venous cannula was removed by suturing and manual compression. Although removing the percutaneous VA-ECMO decannulation and hemostasis were successful, angiography revealed a femoral AVF (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e-B, \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e-C). The fistula had a long and wide neck and was considered to have developed when VA-ECMO was inserted. In this case, we thought that a percutaneous closure was better than a surgical approach because the patient had a high surgical risk as a result of the severe myocardial infarction and required dual antiplatelet therapy.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eFirst, we dilated an intravascular balloon on the arterial side for 15 minutes to block blood flow to the fistula, but the fistula did not reduce at all. Therefore, we closed the AVF percutaneously using a Perclose ProGlide device (Abbott Vascular). We punctured the AVF directly with a 21-G metal needle (Merit Advance angiography needle; Merit Medical) under fluoroscopic guidance. A 0.014-inch guidewire (Gladius MGES guidewire; Asahi Intec) was inserted from behind the needle, and the guidewire was advanced into the right superficial femoral artery (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e-D). A Corsair Armet microcatheter (Asahi Intecc) was inserted into the inner cylinder of the 6-Fr sheath to reduce the gap between the inner sheath and the 0.014-inch wire. The 6-Fr sheath was inserted, and the 0.014-inch wire was replaced with a 0.035-inch Radifocus wire, and we used the Perclose ProGlide device to occlude the AVF (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e-E). Subsequently, an intravascular balloon was dilated on both the arterial and venous sides, and manual compression was applied (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e-F). Angiography confirmed that the AVF was almost completely occluded (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e-G). The subsequent course was good, and the patient was discharged from the hospital. A lower extremity vascular ultrasound performed six months later showed resolution of the AVF (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"3. Discussion","content":"\u003cp\u003eWe demonstrated that percutaneous AVF closure using a Perclose ProGlide device is an option for less invasive treatment of an iatrogenic AVF. The fistula was wide and clearly visible on angiography, so we were able to treat it by directly puncturing the fistula and inserting a Perclose ProGlide device into the femoral artery. If anatomically feasible, it may be possible to puncture the femoral artery, pass the guidewire through the fistula, and insert the Perclose ProGlide device. However, in this case, based on the angiographical findings, it was determined that approaching from the fistula side would make it easier to insert the device.\u003c/p\u003e\u003cp\u003eThere are several reports of EVT for iatrogenic femoral AVF using a stent graft. Good results have been reported for AVF closure [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. By contrast, the need for long-term dual antiplatelet therapy and the risk of in-stent thrombosis are problematic [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Implantation of a stent graft in the CFA carries the risk of compression or kinking due to its superimposition with the hip joint, which may preclude subsequent ipsilateral femoral catheterization. Moreover, lesions at the femoral arterial bifurcation carry the risk of occluding the deep femoral artery after stent-graft placement. Stent-graft placement in the CFA should be avoided because of the risk of deep femoral artery occlusion and the disadvantage of limiting the access route the next time a catheter is needed [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. There have been case reports of embolization using a coil or \u003cem\u003eN\u003c/em\u003e-butyl-2-cyanoacrylate, but the risk of distal embolization should be considered. In cases where the neck of the arteriovenous fistula is long enough, embolization may be relatively safe, but it may not be suitable for cases with short or large neck [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn the present case, the neck of the AVF was large and located at the CFA, so the previously reported EVT methods were unsuitable. The Perclose ProGlide device is widely used as a vascular closure system. Although no reports have described its use for the closure of a femoral AVF, similar applications have been reported in the treatment of pseudoaneurysms with the device [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In these cases, the pseudoaneurysm was directly punctured, and a guidewire was passed through the neck of the pseudoaneurysm into the femoral artery, where it was sutured on the arterial wall side.\u003c/p\u003e\u003cp\u003eOnce access was established, the device was deployed to close the neck of the pseudoaneurysm. Using this procedure, all eight reported pseudoaneurysms were successfully occluded without complications [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. This approach requires a wire and closure device to traverse the neck of the pseudoaneurysm; therefore, it is less suitable for cases with a long and tortuous neck. In such situations, embolization techniques may be a more suitable option. Conversely, lesions with a short and wide neck, particularly those in the CFA that are not amenable to embolization or covered stent placement, may benefit from this closure strategy. In this case, the finding was detected during angiography while performing the ECMO removal procedure in the catheterization lab, and the procedure was performed immediately. It may be considered desirable to perform a CT angiogram preoperatively. To evaluate vascular characteristics, the structure of the neck, and relationships with surrounding structures, and to perform the procedure more safely, we hypothesize that similar considerations may apply to the treatment of femoral AVFs. Although our report describes only a single case, it suggests that Perclose ProGlide closure may be a suitable alternative in select cases. Further investigations and the accumulation of case report data are warranted to clarify its role in this setting.\u003c/p\u003e\u003cp\u003eThis case was concluded with no complications. However, the efficacy and safety of our method remain unknown because of the single case. A much larger study and long-term follow-up are needed to confirm the safety and efficacy of our method.\u003c/p\u003e"},{"header":"4. Conclusions","content":"\u003cp\u003eThis interventional technique using a Perclose ProGlide closure device may offer a feasible treatment option for iatrogenic AVFs, particularly those with a short and wide neck or involving the CFA, where conventional techniques such as embolization or stent-graft placement may not be suitable.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eAVF, arteriovenous fistula; CFA, common femoral artery; CFV, common femoral vein; EVT, endovascular therapy; (VA-ECMO) venoarterial extracorporeal membrane oxygenation.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll procedures were performed in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. The study was approved by the Institutional Review Board (IRB) of Asahi General Hospital.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and any accompanying images.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during the current study are not publicly available because individual privacy could be compromised but are available from the corresponding author upon reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNH received honoraria from Terumo, Kaneka Medix, Medicos Hirata, Boston Scientific, Medtronic, and Becton, Dickinson and Company. The other authors report no conflicts of interest.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo specific grant from any funding agency in the public, commercial, or not-for-profit sectors was received for this report.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the authors have read the manuscript and have approved this submission. HK, NH, HM, YT, SI, SH performed the procedures and pre- and post-procedure follow-ups. HK and NH were major contributors in writing the manuscript. KM drafted the manuscript and revised it critically for important intellectual content. SK provided final approval of the submitted manuscript. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank Robin James Storer, PhD, from Edanz (https://jp.edanz.com/ac) for editing a draft of this manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eZilinyi RS, Sethi SS, Parikh MA, Parikh SA. Iatrogenic arteriovenous fistula following femoral access precipitating high-output heart failure. JACC Case Rep. 2021;3:421-4.\u003c/li\u003e\n \u003cli\u003eKelm M, Perings SM, Jax T, Lauer T, Schoebel FC, Heintzen MP, et al. Incidence and clinical outcome of iatrogenic femoral arteriovenous fistulas implications for risk stratification and treatment. J Am Coll Cardiol. 2002;40:291-7.\u003c/li\u003e\n \u003cli\u003eJin L, Wang J, Wu C, Shao C, Yu X, Lei W. Femoral arteriovenous fistula associated with leg swelling 6 months after removal of a hemodialysis catheter: a case report. Medicine. 2015;94:e1738.\u003c/li\u003e\n \u003cli\u003eThavarajan D, Bakran A. Iatrogenic arteriovenous fistula in the groin presenting as cardiac failure. NDT Plus. 2009;2:46-8.\u003c/li\u003e\n \u003cli\u003eSan Norberto Garc\u0026iacute;a EM, Gonz\u0026aacute;lez-Fajardo JA, Guti\u0026eacute;rrez V, Carrera S, Vaquero C. Femoral pseudoaneurysms post-cardiac catheterization surgically treated: evolution and prognosis.\u0026nbsp;Interact Cardiovasc Thorac Surg. 2009;8:353-7.\u003c/li\u003e\n \u003cli\u003eOnal B, Kosar S, Gumus T, Ilgit ET, Akpek S. Postcatheterization femoral arteriovenous fistulas: endovascular treatment with stent-grafts. Cardiovasc Intervent Radiol. 2004;27:453-8.\u003c/li\u003e\n \u003cli\u003eThalhammer C,\u0026nbsp;Kirchherr\u0026nbsp;AS, Uhlich\u0026nbsp;F, Waigand\u0026nbsp;J, Gross\u0026nbsp;CM. Postcatheterization pseudoaneurysms and arteriovenous fistulas: repair with percutaneous implantation of endovascular covered stents. Radiology. 2000;214:127-31.\u003c/li\u003e\n \u003cli\u003eOnal B, Ilgit ET, Akpek S, Coskun B. Postcatheterization femoral arteriovenous fistula: endovascular treatment with \u003cem\u003eN\u003c/em\u003e-butyl-cyanoacrylate embolization. Cardiovasc Intervent Radiol. 2006;29:276-8.\u003c/li\u003e\n \u003cli\u003eGooneratne T, Chanaka KAN, Wijeyaratne SM. An unusual case of femoral arteriovenous fistula associated with acute limb ischemia following femoral vein catheterization for hemodialysis. J Vasc Bras. 2022;21:e20210199.\u003c/li\u003e\n \u003cli\u003eHayakawa N,\u0026nbsp;Tobita\u0026nbsp;K, Kodera\u0026nbsp;S, Ishibashi\u0026nbsp;N, Kasai\u0026nbsp;Y, Arakawa\u0026nbsp;M, et al.\u0026nbsp;An effective method for percutaneous removal of venoarterial extracorporeal membrane oxygenation by a combination of balloon dilatation in endovascular therapy and the Perclose Proglide\u0026trade; closure device. Ann Vasc Surg. 2021;73:532-7.\u003c/li\u003e\n \u003cli\u003eRathod JR, Dhomne S, Taori K, Prasad KP, Guha A. Endovascular stent graft for post-traumatic superficial femoral artery pseudoaneurysms with arteriovenous fistula: 6 months follow-up of 2 cases. J Radiol Case Rep. 2011;5:26-34.\u003c/li\u003e\n \u003cli\u003eInagaki Y, Nakao M, Arashi H, Yamaguchi J.\u0026nbsp;Novel interventional technique for the treatment of an iatrogenic pseudoaneurysm of the brachial artery.\u0026nbsp;J Cardiol Cases. 2021;25:250-3.\u003c/li\u003e\n \u003cli\u003eIbrahim K, Christoph M, Wunderlich C, Jellinghaus S, Loehn T, Youssef A, et al. A novel interventional method for treating femoral pseudoaneurysms: results from a monocentric experience. EuroIntervention. 2017;13:366-70.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"cvir-endovascular","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cire","sideBox":"Learn more about [CVIR Endovascular](https://www.springer.com/journal/42155)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/cire/default.aspx","title":"CVIR Endovascular","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Iatrogenic femoral arteriovenous fistula, Perclose ProGlide, endovascular therapy","lastPublishedDoi":"10.21203/rs.3.rs-7807167/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7807167/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Iatrogenic femoral arteriovenous fistula (AVF) is a representative complication of a percutaneous femoral approach to cannulation. Because open surgical repair is highly invasive, endovascular treatment for AVFs is receiving increasing attention. We report a case of successful percutaneous AVF closure using a Perclose ProGlide closure device.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation:\u003c/strong\u003e A 56-year-old man underwent percutaneous venoarterial extracorporeal membrane oxygenation decannulation and hemostasis. Final angiography showed an AVF, with a short and wide neck. We directly punctured the fistula with fluoroscopic guidance using a 21-G puncture needle. A 0.014-inch wire was inserted and replaced with a 0.035-inch wire, and the arteriovenous fistula was occluded using the Perclose ProGlide device. We performed additional balloon dilation to occlude blood flow to the AVF from the femoral artery and vein. The shunt flow almost completely disappeared, and complete disappearance of the AVF was confirmed by vascular ultrasound 6 months later.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e This interventional technique using a Perclose ProGlide devicemay offer a treatment option for iatrogenic AVFs, particularly those with a short and wide neck or those involving the common femoral artery, where conventional techniques may not be suitable\u003c/p\u003e","manuscriptTitle":"Percutaneous closure using a Perclose ProGlide device for an iatrogenic femoral arteriovenous fistula caused by venoarterial extracorporeal membrane oxygenation insertion: A case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-27 15:20:24","doi":"10.21203/rs.3.rs-7807167/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"","date":"2025-10-13T05:47:12+00:00","index":0,"fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-13T01:19:28+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-10T08:17:18+00:00","index":"","fulltext":""},{"type":"submitted","content":"CVIR Endovascular","date":"2025-10-08T07:07:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"cvir-endovascular","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"cire","sideBox":"Learn more about [CVIR Endovascular](https://www.springer.com/journal/42155)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/cire/default.aspx","title":"CVIR Endovascular","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"6f71ef24-6300-460c-8b45-ea453d4c5382","owner":[],"postedDate":"October 27th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-04-13T16:02:24+00:00","versionOfRecord":{"articleIdentity":"rs-7807167","link":"https://doi.org/10.1186/s42155-026-00683-x","journal":{"identity":"cvir-endovascular","isVorOnly":false,"title":"CVIR Endovascular"},"publishedOn":"2026-04-09 15:58:17","publishedOnDateReadable":"April 9th, 2026"},"versionCreatedAt":"2025-10-27 15:20:24","video":"","vorDoi":"10.1186/s42155-026-00683-x","vorDoiUrl":"https://doi.org/10.1186/s42155-026-00683-x","workflowStages":[]},"version":"v1","identity":"rs-7807167","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7807167","identity":"rs-7807167","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}