Vessel wall avulsion following incomplete closure with perclose ProStyle: A rare complication

A 67-year-old man with severe carotid stenosis underwent carotid artery stenting via the right femoral access using an 8F sheath.Postoperative angiography confirmed the absence of complications at the puncture site of the right femoral artery.We used the Perclose ProStyle suturemediated closure system (Abbott Vascular, SC, CA, USA) for arterial closure.After suture tightening, the ligature and a portion of the arterial wall tissue unexpectedly dislodged during excess suture trimming (A).Nevertheless, the resulting bleeding was controlled with manual compression for 20 minutes.The extracted specimen was thin and identifiable as nonadventitial tissue, prompting us to plan follow-up imaging after achieving hemostasis.One month postoperatively, computed tomography angiography and ultrasound examination revealed a luminal step (B) and a flap, respectively, distal to the puncture site.The patient provided written informed consent to report case details and imaging findings.Histological examination of the extracted tissue revealed predominantly degenerated and calcified tunica media (C).Elastica van Gieson staining revealed partial preservation of elastic fibers in the internal elastic lamina, indicating dissection between the media and intima (D/cover).Atherosclerotic changes are generally localized, leading to the expectation of nonuniform progression of atherosclerosis in each layer.The tightly closed knot on the extracted suture suggests that excessive force during ligation may have sheared the adventitia, considering the strength of the vessel.In the present case, postoperative imaging revealed the formation of a dissection-like lesion in the parent vessel, primarily owing to a pull-out injury involving the tunica media.This raised concerns about potential pseudoaneurysm formation; however, the 3-month postoperative followup showed no changes in the findings.This case is the second to be reported of this extremely rare complication. 1 We confirmed with the distributor that there were no other similar reported cases.This case study highlights the importance of exercising particular caution when using the Perclose ProStyle in vessels with severe atherosclerotic changes, especially regarding the strength of ligation and risk of intimal pull-out injury.Excessive ligation should be avoided, and bleeding from the puncture site should be tolerated after appropriate suture tension has been applied.