DISCUSSION
For both of our patients, femoral access was not feasible secondary to
large clot burden and fear of paradoxical embolus while inserting
equipment in the femoral-iliac venous system. Options for access for PFO
closure device includes: 1) trans-jugular and 2) trans-hepatic. The
procedure could be done with TEE guidance although ICE has been the
predominant imaging modality for PFO closures in the US. Options for
access for ICE catheter include: 1) trans-jugular, 2) trans-hepatic or
3) left upper extremity venous access.
TEE requires general anesthesia and requires another operator to
perform, thus we decided to perform the procedure with ICE guidance
through the left upper extremity venous system utilizing the jugular
vein for PFO closure.
Since trans-hepatic access can be complex, we elected to use the arm and
the jugular veins to perform these procedures.