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.