Balloon–trapping Retrieval of a Fractured Femoral Sheath During Pulsed Field Ablation for Atrial Fibrillation

Background Catheter ablation for atrial fibrillation (AF) is technically demanding, and vascular access complications remain among the most frequent and clinically important adverse events. Although ultrasound–guided femoral puncture has improved safety, multiple venous punctures, large–bore sheaths, and full anticoagulation mean that rare, potentially life–threatening complications can still occur. Case Description A 69–year–old man with ischemic dilated cardiomyopathy and a prior implantable cardioverter–defibrillator (ICD) was referred for pulsed–field ablation (PFA) for symptomatic AF refractory to maximal medical therapy, with recurrent inappropriate ICD shocks. During acquisition of dual right femoral venous access under ultrasound guidance, a 7–French introducer sheath kinked and ruptured after contact with an advancing SL0 long sheath. Venography confirmed retention of the distal fragment in the right femoral vein. A multidisciplinary team, including an interventional radiologist and a vascular surgeon, was promptly activated, and an endovascular–first retrieval was pursued via contralateral femoral access. After unsuccessful gooseneck snare attempts, balloon–assisted retrieval was performed: an 8–French Cook sheath was advanced from the left femoral vein; a 4–French Berenstein catheter with a 0.035″ guidewire engaged the fragment lumen; (Fig.1) the 0.035″ wire was exchanged for a 0.014″ wire and the catheter for a 4.0 × 30–mm semi–compliant balloon, advanced into the fragment, inflated, (Fig.2) and used to pull it to the left femoral vein for controlled extraction (Fig.3). Final venography demonstrated preserved bilateral venous integrity. PFA was then completed uneventfully through the remaining secure accesses, achieving complete pulmonary vein isolation. At three–month follow–up, the patient remained in sinus rhythm without arrhythmic events or vascular sequelae. Conclusions This case illustrates an uncommon but high–risk access complication—introducer sheath rupture with intravascular fragment retention—despite ultrasound guidance. Rapid recognition, venographic confirmation, and multidisciplinary involvement enabled a conservative endovascular strategy, avoiding open venous exploration. Early diagnosis and coordinated management are essential. When feasible, an endovascular–first approach—using balloon–assisted techniques when snaring fails—can be safe and effective, preserving venous integrity.Figure 1 Figure 2 Figure 3