Troubleshooting Vascular Tortuosity in High Risk Percutaneous Coronary Intervention: Managing Impella Sheath Challenges

Transfemoral Impella placement can be technically challenging in patients with severe iliofemoral tortuosity and calcification, often leading to sheath kinking, failed device advancement and vascular complications. In this complex, high-risk percutaneous coronary intervention (PCI) case, Impella CP insertion was impeded by severe tortuosity. The issue was successfully addressed by exchanging the standard Impella 14 French sheath with a 16 French Gore DrySeal sheath, which enabled smooth device delivery and completion of PCI. The Gore DrySeal sheath, originally designed for complex aortic procedures, offers enhanced flexibility, kink resistance, and hydrophilic coating that improve trackability in tortuous anatomy. Review of the literature supports its off-label use in similar challenging vascular access scenarios. This case highlights the potential role of the Gore DrySeal sheath as a valuable tool in facilitating large-bore device placement through complex arterial pathways.