Removal of a Broken Femoral Sheath Tip With Balloon Angioplasty Trapping

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J INVASIVE CARDIOL 2025. doi:10.25270/jic/24.00361. Epub January 8, 2025.

A 67-year-old woman underwent pulmonary vein isolation with radiofrequency ablation (RFA) for the treatment of recurrent paroxysmal atrial fibrillation. A 6-French (Fr) and an 8-Fr femoral sheath (Medtronic) were placed into the right femoral vein. A coronary sinus catheter was inserted into the coronary sinus through a 6-Fr sheath. Successful radiofrequency isolation of the pulmonary veins was performed with the CARTO system (J&J).

At the end of the procedure, a figure-of-8 suture was applied, and the sheaths were removed. While 1 operator performed the sutures, the other operator retracted the sheaths. When the sheaths were retracted, it was observed under fluoroscopy that the suture had cut the 6-Fr sheath, and the broken femoral sheath tip was still in the femoral vein (Figure A).

An 8-Fr sheath (Medtronic) was placed in the left femoral vein. The broken sheath tip was revealed by fluoroscopy (Figure A). Since there was no appropriate snare, we considered removing the broken femoral sheath tip with balloon angioplasty trapping. We first attempted to cross the 0.014-inch guidewire into the lumen of the fractured sheath via a 7-Fr Judkins right (JR4) guiding catheter. Then, we inflated a 2.5 x 15-mm balloon at 16 atm inside the broken femoral sheath tip (Figure B). The broken sheath tip, inflated balloon, and JR4 catheter were withdrawn and removed from the left femoral vein via the simple traction method (Figure C and D, Video). The patient was discharged the following day, without complication.  

As the number of percutaneous procedures increases, there may be an increase in the prevalence of unexpected complications (such as catheter and sheath fractures, and embolization). In addition, fragmented and embolized sheaths may lead to venous perforation, cardiac rupture or tamponade, various arrhythmias, and pulmonary hypertension. The fractured sheath should be retrieved percutaneously, which is the first and most common method, or, in rare cases, surgically. The success rate of retrieval techniques depends on the location of the broken sheath and its tip and whether there is sheath lumen or migration, among other factors. Other percutaneous retrieval methods include the goose-neck loop snare, proximal or distal grab techniques, balloon catheter techniques, basket catheters, biopsy forceps, and guidewire techniques (such as hairpin trap and 2-wire trap). Although percutaneous retrieval of the broken sheaths may present some difficulties, the success rate is very high provided that the appropriate materials and techniques are chosen.

Affiliations and Disclosures

Murat Akçay, MD; Esra Temiz Lafcı, MD; Serkan Yuksel, MD

From the Department of Cardiology, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey.

Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.

Consent statement: Written informed consent was obtained from the patient for publication of this case report.

Artificial intelligence statement: The authors did not use any artificial intelligence (AI)– assisted technologies (such as large language models [LLMs], chatbots, or image creators) in the production of submitted work.

Address for correspondence: Murat Akcay, MD, Department of Cardiology, Ondokuz Mayis University, Samsun, Turkey. Email: drmuratakcay@hotmail.com