An Unusual Femoral Sheath Severing with Successful Recapture: A Case Report

This study presents a case of a successful severed femoral sheath recapture during transfemoral transcatheter aortic valve replacement (TAVR). During skin tunneling with a scalpel, the discontinuity of the femoral sheath occurred. Grasping of the distal sheath with the surgical hemostat was attempted unsuccessfully. A proximal part of the severed sheath was removed and Medtronic Sentrant introducer sheath (14 French) was then placed over the existing Confida wire which permanently remained in position, followed by the introduction of the Amplatz Left 2 (AL2) catheter which pushed the severed sheath in the ascending aorta over the Confida wire. The crucial maneuver was the entanglement of the severed sheath in the aortic non-coronary cusp which allowed for its entrapment by the AL2 catheter. This allowed for the coronary guidewire BMW Universal (0.014”) placement and a slow balloon retrieval (SeQuent NEO 2.5 x 25 mm) of the severed sheath into the introducer sheath. The guidewire/balloon catheter was then exchanged for the support wire (0.035”) followed by the removal of the introducer sheath, AL2 catheter and the severed sheath. In conclusion, sheath severing is a complex accidental event during TAVR, which can be solved by intra-aortic recapture and retraction.

Recanalization and Stenting of the Celiac and the Superior Mesenteric Artery Supported by Use of a Steerable Introducer Sheath: Report on 2 Years’ Experience

Purpose: To compare technical parameters and success of recanalization of celiac (CA) or superior mesenteric artery (SMA) with usage of steerable vs not steerable introducer sheaths. Methods: A retrospective analysis was performed on all consecutive patients who underwent recanalization with stent implantation of CA or SMA between 2015 and 2019. Data regarding technical success (successful stent placement with restoration of sufficient blood flow by the first attempt without changing kind of introducer sheath or access site), indication for treatment, vascular access, kind of introducer sheath, fluoroscopy time and radiation dose were collected. Preinterventional CT were analyzed to classify the difficulty of catheterization of target vessels. Technical parameters were compared with independent t-test (p ≤ 0.05). Results: 66 patients underwent recanalization of CA or SMA. Usage of steerable introducer sheaths was associated with higher technical success compared to not steerable introducer sheaths with transfemoral approach respectively of 8/8 vs 15/19 for the CA and 11/11 vs 17/20 for the SMA. Steerable introducer sheaths were used in recanalization considered more technically difficult compared to not steerable introducer sheaths (58% vs 33%). Usage of steerable introducer sheath showed a statistically significant reduction of radiation dose in the recanalization of the SMA (respectively 32035 ± 15716 cGy cm2 vs 60102 ± 28432 cGy cm2; p = 0.005). Conclusion: Even if used in more difficult interventions, steerable introducer sheaths showed a higher technical success compared to not steerable introducer sheaths with transfemoral access.

Non-invasive removal of self-locking entrapped nephrostomy tubes

Introduction: The removal of an encrusted nephrostomy tube can be a challenging maneuver. Urological literature is very bare in detailing techniques for removal of entrapped percutaneous catheters. We present a simple, safe and non-invasive technique of nephrostomy removal using a vascular introducer sheath, useful to manage complicated situations such as nephrostomies blocked for severe encrustations or disabled in their self-locking system. Surgical technique: The nephrostomy tube is cut and the stump is passed with a suture needle. The suture is passed through the inner vascular introducer sheath tip, and the introducer is then removed. The introducer sheath is advanced over the nephrostomy until joining the pigtail segment, under fluoroscopy guidance. Thus the suture is pulled out with strenght to contrast the opposite stiffness of the encrusted coil, until the nephrostomy has safely come out. Comment: The sheath exchange technique is quick, involves less manipulation through the perirenal fascia and kidney, and is suitable for different conditions of entrapped nephrostomies.

Novel Choices of Cannula for Blood Delivery via Femoral Artery in Pediatric Patients

We previously presented a cardiopulmonary bypass (CPB) method with blood delivery via femoral artery cannulation for pediatric aortic arch repair operations using the Radifocus Introducer sheath. However, the flow rate with the Radifocus Introducer sheath is limited by accessory parts with the same structure having a smaller inner diameter among different sizes, rather than the sheath body. Therefore, we further devised a combination of the JELCO IV catheter, an extension tube, and a three-way stopcock with a larger opening to obtain more flow rate keeping the CPB circuit pressure significantly lower than when using the Radifocus Introducer sheath successfully.