Bailout of long-sheath tip separation during noncontrast transfemoral transcatheter aortic valve replacement

Figures

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  Unexpected marker prompting recognition of long-sheath tip separation.

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  Figure 1. Preprocedural access evaluation and fluoroscopic recognition of long-sheath tip separation. A, Axial noncontrast computed tomography image showing severe calcification of the left common iliac artery (arrow). B, Coronal noncontrast computed tomography image showing calcification of the left common iliac artery near the aortic bifurcation (arrow). C, Magnetic resonance angiography showing suspected irregular plaque in the aortic arch (dotted arrow). D, Fluoroscopic image obtained before valve deployment, showing an unexpected radiopaque marker near the nose cone of the Evolut FX delivery system. The arrowhead indicates the marker, which did not follow withdrawal of the DrySeal sheath, prompting suspicion of sheath-tip separation.

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  Figure 2. Schematic illustration of sheath-tip separation, catheter-wire entanglement, and surgical bailout. A, The separated DrySeal tip remained connected to the sheath body by the helical support structure, and the SAFARI guidewire traversed the tip lumen. B, The separated component became caught at the calcified aortoiliac segment, and the contralateral catheter-wire system could become entangled with the helical support structure. Gray hatching indicates vascular calcification. C, Traction on the support structure brought the retained component to the ipsilateral femoral segment, where proximal control and surgical exposure enabled removal.