Unexpected marker prompting recognition of long-sheath tip separation.
Central Message.
Unexpected radiopaque markers during valve delivery should prompt suspension of deployment; tethered sheath-tip separation may require wire control and surgical bailout.
Long introducer sheaths may facilitate transfemoral transcatheter aortic valve replacement (TAVR) in unfavorable iliofemoral or aortic anatomy by reducing interaction with diseased vascular segments.1 However, calcified or narrowed access can transfer stress to the sheath tip or transition zone. Noncontrast planning in chronic kidney disease or severe contrast allergy further limits precise luminal assessment.2 Sheath disruption during TAVR has been reported with expandable sheaths,3,4 and sheath-tip fracture also has been described during endovascular aneurysm repair.5 We describe the bailout of long-sheath tip separation during noncontrast TAVR with a self-expanding valve.
Case
An 85-year-old man with severe aortic stenosis presented with decompensated heart failure. His medical history included coronary artery bypass grafting, lower-extremity arterial disease, diabetes, chronic kidney disease (creatinine, 2.5 mg/dL), and anaphylactic shock to iodinated contrast media. Noncontrast computed tomography, magnetic resonance angiography, and transesophageal echocardiography were used for planning. The minimum left iliac artery diameter was approximately 7.2 mm, with three-quarter circumferential calcification, and irregular arch plaque was suspected. Alternative access was considered; direct aortic access was unfavorable because of porcelain aorta, and trans-subclavian access was limited by severe arch-branch calcification. To reduce device interaction with diseased iliofemoral and aortic segments, an 18-F, 65-cm GORE DRYSEAL Flex Introducer Sheath (WL Gore & Associates) was advanced from the left femoral artery to the ascending aorta after 8-mm balloon predilation of the calcified iliac segment, with no significant balloon waist or deformation, supporting the feasibility of sheath passage. A 26-mm Evolut FX transcatheter aortic valve system (Medtronic) was selected.
After balloon aortic valvuloplasty with an 18-mm Inoue balloon, the Evolut FX delivery system was advanced through the DrySeal sheath into the left ventricle (LV). Before deployment, an unfamiliar radiopaque marker was observed near the nose cone (Figure 1 and Video 1). The marker was initially interpreted as unintended advancement of the DrySeal sheath but did not follow sheath withdrawal. Deployment was suspended, and sheath-tip separation was suspected.
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.
The Evolut FX delivery system was withdrawn without deployment. The separated sheath tip initially moved with the delivery system but detached in the descending aorta and remained intravascular. The SAFARI guidewire (Boston Scientific) was preserved in the LV because it traversed the separated tip lumen and provided partial control. The thin helical support structure was poorly visible fluoroscopically, and continuity between the separated tip and sheath body was not recognized. A 6-mm angioplasty balloon failed to anchor the mobile separated tip and instead pushed it proximally (Video 2). Because contralateral retrieval risked entanglement, an ipsilateral Fogarty balloon catheter (Edwards Lifesciences) was used to control the tip and pull it to the aortoiliac bifurcation. The component could not be retrieved across the calcified iliac segment. The distal sheath body was removed externally, and the support structure was divided. Controlled traction was applied to its free end under continuous fluoroscopy while monitoring the aortoiliac segment. During traction, the contralateral guidewire moved with the component, suggesting catheter-wire entanglement (Figure 2 and Video 3). The separated tip, support structure, and entangled catheter-wire system were brought to the ipsilateral iliac–proximal femoral segment.
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.
Because further traction from this point was considered to increase the risk of vascular injury, femoral cutdown was selected for controlled removal under direct visualization. The preplaced closure suture was tied while the SAFARI guidewire remained in place. The left common femoral artery was exposed and encircled with vessel loops, and fluoroscopy confirmed that proximal control could be obtained upstream of the retained component. After arteriotomy, the retained sheath tip and helical support structure were removed, and the contralateral guidewire was retrieved through the contralateral access. Because LV wire access was preserved, the Evolut FX inline sheath was advanced through the same femoral access before femoral repair and passed smoothly through the calcified left common iliac artery. The Evolut FX valve was implanted under transesophageal echocardiographic guidance. Carbon dioxide angiography confirmed no left iliofemoral injury (Video 4), and the left common femoral artery was repaired. No iodinated contrast was used.
The patient was extubated immediately, with no stroke or clinically evident embolic complications. Transient complete atrioventricular block developed on postoperative day 6 and resolved without permanent pacemaker implantation. Echocardiography showed a mean gradient of 5 mm Hg and mild paravalvular leak. Discharge on postoperative day 28 was delayed by left-groin wound healing. Renal function remained stable at 1 year.
Technical Lessons
This case provides 3 technical lessons.
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Valve deployment should be suspended when an unexpected radiopaque marker appears until its origin and sheath integrity are clarified.
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Wire control of the separated tip should be preserved when safe.
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Although DrySeal sheath-tip fracture has been reported during endovascular aneurysm repair,5 a separated DrySeal tip may remain tethered to the sheath body rather than behave as a simple free intravascular foreign body, and contralateral catheter-wire manipulation may worsen entanglement. Balloon control may help stabilize the component, but early femoral cutdown should be considered when retrieval fails or entanglement is suspected.
Conclusions
Manufacturer evaluation found no definitive cause; distal mechanical stress from calcification, sheath bending, or device passage remained possible. Similar tethered DrySeal Flex separations have been reported postmarketing. Noncontrast computed tomography and magnetic resonance angiography may incompletely characterize calcified iliofemoral access; intravascular ultrasound may complement assessment in borderline cases, with a low threshold to consider alternative access when safe sheath passage is uncertain. This event was considered a sheath-related complication, although the contribution of hostile access anatomy remains uncertain.
Declaration of Generative AI and AI-Assisted Technologies in the Writing Process
The authors used Paperpal to assist with the English language editing and manuscript formatting and take full responsibility for the submitted manuscript.
Conflict of Interest Statement
The authors reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
Footnotes
Institutional Review Board approval was not required for this single case report, as determined by the Nagano Chuo Hospital Ethics Committee (NCH26-08; July 15, 2026).
Written informed consent for publication was obtained from the patient.
Present address for N.M.: Department of Cardiovascular Surgery, Yachiyo Medical Center, Tokyo Women's Medical University, Yachiyo, Chiba, Japan.
Supplementary Data
Unexpected radiopaque marker before valve deployment. An unfamiliar marker appeared near the nose cone and did not follow sheath withdrawal; valve deployment was suspended. Video available at: https://www.jtcvs.org/article/S2950-6050(26)00050-1/fulltext.
Tip detachment and unsuccessful balloon anchoring. The separated DrySeal sheath tip detached in the descending aorta during delivery-system withdrawal. Initial 6-mm balloon anchoring failed because the mobile tip was pushed proximally. Video available at: https://www.jtcvs.org/article/S2950-6050(26)00050-1/fulltext.
Failed retrieval and support-structure traction. Fogarty balloon retrieval at the aortoiliac bifurcation failed, and traction on the support structure brought the tip toward the femoral segment. Contralateral guidewire movement suggested catheter-wire entanglement. Video available at: https://www.jtcvs.org/article/S2950-6050(26)00050-1/fulltext.
Completion of TAVR after femoral cutdown. After surgical removal of the retained component, the valve implantation was completed through the same femoral access, and carbon dioxide angiography confirmed no left iliofemoral injury. Video available at: https://www.jtcvs.org/article/S2950-6050(26)00050-1/fulltext.
References
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Unexpected radiopaque marker before valve deployment. An unfamiliar marker appeared near the nose cone and did not follow sheath withdrawal; valve deployment was suspended. Video available at: https://www.jtcvs.org/article/S2950-6050(26)00050-1/fulltext.
Tip detachment and unsuccessful balloon anchoring. The separated DrySeal sheath tip detached in the descending aorta during delivery-system withdrawal. Initial 6-mm balloon anchoring failed because the mobile tip was pushed proximally. Video available at: https://www.jtcvs.org/article/S2950-6050(26)00050-1/fulltext.
Failed retrieval and support-structure traction. Fogarty balloon retrieval at the aortoiliac bifurcation failed, and traction on the support structure brought the tip toward the femoral segment. Contralateral guidewire movement suggested catheter-wire entanglement. Video available at: https://www.jtcvs.org/article/S2950-6050(26)00050-1/fulltext.
Completion of TAVR after femoral cutdown. After surgical removal of the retained component, the valve implantation was completed through the same femoral access, and carbon dioxide angiography confirmed no left iliofemoral injury. Video available at: https://www.jtcvs.org/article/S2950-6050(26)00050-1/fulltext.