Managing Hostile Aortic Anatomies Using an Extended-Length Introducer Sheath During Transfemoral Transcatheter Aortic Valve Replacement: Rationale and Clinical Outcomes

Background Transfemoral (TF) access is the safest and guideline-recommended approach for transcatheter aortic valve replacement (TAVR). However, in patients with hostile aortic anatomies, the procedure may carry increased risks of vascular or cerebrovascular complications. The objective of this article is, therefore, to evaluate the safety and efficacy of using the extended-length DrySeal Flex introducer sheath (Gore, USA) for TF-TAVR in high-risk patients with challenging aortic anatomies. Methods We conducted a retrospective, single-center cohort study including all consecutive patients who underwent TF-TAVR with the 65-cm DrySeal sheath between 2021 and 2025. We analyzed the indications for sheath use and the following clinical outcomes: all-cause mortality, stroke, and major vascular complications as defined by Valve Academic Research Consortium-3 criteria. Results The 65-cm DrySeal sheath was used in 200 patients (median age 80 years; median Society of Thoracic Surgeons score 5.4%) out of 2430 (8.2%) TF-TAVR procedures performed. This approach was selected to address challenges posed by aortic arch calcification (28%), heavily atheromatous or shaggy aorta (20%), acute aortic angulation (26%), tortuosity (36%), and aortic coarctation (8%). In this high-risk cohort, all-cause mortality was 0.5%, stroke occurred in 1.5% (including 0.5% with disabling stroke), and major vascular complications were observed in 1.0%. These outcomes were comparable to those seen in lower-risk patients undergoing TF-TAVR using conventional approaches. Conclusions In patients with hostile aortic anatomies, the extended-length DrySeal Flex introducer sheath facilitated safe and effective TAV delivery and was associated with a low rate of periprocedural complications, including cerebrovascular events. Its use may help mitigate the risks traditionally associated with hostile aortic anatomies.