Abstract Body (Do not enter title and authors here): Introduction: Mechanical Circulatory Support (MCS) is increasingly used in patients with cardiogenic shock (CS) or compromised hemodynamics during high-risk percutaneous coronary or structural interventions. Safe removal of large-bore MCS devices and closure of arteriotomy sites are crucial to prevent bleeding and vascular complications. Clot formation within intra-arterial sheaths post-MCS implantation poses a risk of thromboembolic complications, necessitating innovative approaches for safe removal.

Case presentation: We present a 69-year-old male with a history of multivessel coronary artery disease (CAD), who was admitted with CS due to non-ST-segment elevation myocardial infarction (NSTEMI) requiring Impella CP device implantation. He later demonstrated hemodynamic stability with a heart rate ranging from 70 to 80 beats per minute and a mean arterial pressure (MAP) ranging from 75 to 80 mmHg, with the Impella set at power level 8 (P8). He underwent successful weaning from Impella support per protocol and was subsequently brought to the cardiac catheterization laboratory (CCL) for device explantation. The procedure began with the standard technique; however, upon inspection of the sheath following device removal, a sizable clot was visualized. To prevent embolization, we avoided standard retrograde wiring and instead, a Glide Advantage wire was threaded to the Impella sheath in an antegrade fashion via a contralateral access. A balloon was inflated within the sheath for dry field closure. Subsequently, the balloon and sheath were pulled together, extracting the clot in the process.

Discussion: MCS utilization has risen, necessitating meticulous approaches to arterial access and device removal to mitigate bleeding and vascular complications. In our case, our primary concern revolved around the risk of embolization stemming from the sizable clot observed within the Impella sheath post-device removal when using the standard retrograde technique. This situation posed the potential for serious consequences, including acute limb ischemia, organ ischemia, or cerebrovascular accidents. Consequently, we needed to devise a novel technique for sheath explantation that would ensure safety and effectiveness. Our approach, employing the contralateral access and advancing the wire antegradely, provided a secure alternative, averting the severe consequences associated with clot embolization.