Abstract Body (Do not enter title and authors here): Introduction:
A 79-year-old male patient with a history of surgical AVR presented with severe bioprosthetic aortic stenosis requiring valve-in-valve TAVR. The plan was to place an Evolut CoreValve after intentionally fracturing the basal ring of his surgical valve. Through an 18F sheath, a 25mm x 4.5cm True balloon was advanced to the surgical valve over a Lunderquist wire. However, the balloon ruptured immediately after fracturing the valve ring.
Decision making:
Efforts were made to remove the ruptured True balloon while maintaining the position of the wire, but attempts to withdraw it through the 18F sheath were unsuccessful due to resistance at the distal tip of the sheath. Subsequently, the proximal portion of the balloon catheter was partially detached and removed.
An exchange was made to a 22F Gore DrySeal sheath, but again, efforts to withdraw the ruptured balloon were unsuccessful (Figure 1). Various snares were employed, but all attempts to manipulate the balloon into the sheath were ineffective. The ruptured balloon remained in the abdominal aorta and eventually detached from the hypotube.
The 22F sheath was then exchanged for a 20F Inari Protrieve sheath. Two Supracore wires were then inserted through the sheath, with one designated for snare delivery and the other for maintaining vessel access. A Tulip snare was guided over one Supracore wire to the descending thoracic aorta, where the snare was opened and the Lunderquist wire was captured at the junction between the stiff and soft parts of the wire (Figure 2). The snared wire and ruptured balloon were retracted into the exposed Nitinol cone of the Inari sheath, successfully engulfing the balloon and compressing it (Figure 3). The sheath, wire, balloon, and snare were then removed as a unit while the wire access was maintained.
A new 22F Gore DrySeal sheath was inserted. Inspection confirmed the complete removal of all components of the ruptured True balloon and the catheter. The procedure concluded with the successful deployment of a 29mm Evolut pro CoreValve. The patient made an uneventful recovery and was discharged home the following day.
Conclusion:
The Inari Protrieve sheath proved valuable in this case of complicated intravascular equipment entrapment. The soft, funnel-shaped nitinol cone aided in capturing and compressing the bulky ruptured balloon, obviating the need for a surgical cutdown.