Highlights
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During percutaneous interventions equipment related complications can occur.
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This can be life-threatening especially in high risk procedures like TAVI.
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We report severely kinked TAVI sheath in abdominal aorta, not previously described.
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We outline strategies to overcome this serious complication and review literature.
During percutaneous transcatheter interventions unexpected complications can occur due to failure or deformation of equipment. In order to properly deal with these, correct interpretation and subsequent remedy is essential to avoid potential vascular injury. We hereby present a case of severe kinking and twisting of the sheath within the aorta during Transcatheter Aortic Valve Implantation (TAVI), and its successful removal.
A 71-year-old man with symptomatic severe aortic stenosis and a history of arterial hypertension and type 2 diabetes mellitus was referred for TAVI. All preoperative assessments were satisfactory including arterial phase multidetector computed tomography, there was no significant arterial tortuosity and the minimum vascular dimensions were: common femoral arteries ≥6 mm; external iliac arteries ≥8 mm; common iliac arteries ≥8 mm; abdominal aorta 12 mm; and descending aorta 20 mm.
The patient underwent transfemoral TAVI with a 26 mm Edwards Sapien S3 valve (Edwards Lifesciences, California, USA) via the left transfemoral artery using a 14F Edwards eSheath (Edwards Lifesciences, California, USA). Following valve deployment significant resistance was encountered on removing the delivery system, and on removal it was noted that the balloon itself had not fully deflated. Fluoroscopic imaging of the Edwards eSheath in the aorta revealed a severely deformed sheath in the abdominal aorta, with a kinked tip and a twisted shaft ( Fig. 1 ). Efforts to straighten the sheath by manoeuvering it upwards with guidewire support using a 0.035-inch J-tip guidewire and Terumo hydrophilic guidewire were met with resistance, due to inadequate wire stiffness. These did not provide enough strength to support unkinking of the sheath. Subsequently, the patient complained of back pain, and became hypotensive and bradycardic; he was therefore intubated for stabilisation. In order to exclude aortic dissection or perforation, contrast was injected in the aorta. No extravasation of contrast was observed on the aortogram ( Fig. 2 a ). Since the patient had already complained of back pain, we decided not to push the sheath upwards into the aorta, in case the sharp end of the bent sheath could cause aortic injury and dissection. Therefore, we attempted to straighten the sheath by inserting the introducer into the sheath, and advancing a Lunderquist wire (Cook Medical, Indiana, USA) through it. By simultaneous retraction and counterclockwise rotation of the sheath, pulling it towards the aortic bifurcation with the iliac vessels, while advancing the introducer and the Lunderquist wire forward, we successfully straightened the sheath up in the aorta under fluoroscopy, allowing for successful retrieval of the sheath and a safe recovery. After sheath removal, the right femoral artery access was closed with two Proglide (Abbott Vascular, Santa Clara, CA) devices and an 8F Angioseal (Terumo, Tokyo, Japan) and good haemostasis was achieved. No extravasation or other vascular complications were observed on the final aortogram ( Fig. 2 b). At the end of the procedure the patient was haemodynamically stable, and after extubation he made an uneventful recovery.
