Deploying Steerable Sheath to Improve Safety, Efficiency, and Efficacy of Body and Peripheral Interventions

Abstract

Steerable vascular sheaths are designed to be used in the human vasculature to facilitate the introduction of diagnostic and/or therapeutic devices. Despite a broad indication, steerable sheaths are most commonly used in aortic intervention, particularly when there is a need for access through fenestrations. However, steerable sheaths have a wide variety of interventional radiology (IR) applications in the body and periphery. In this case series, we review the use of a steerable sheath in diverse applications, including arterial embolization, arterial thrombectomy/thrombolysis, stenting/recanalization, urinary, and foreign body retrieval. Steerable sheaths are found to provide enhanced stability of access, improved pushability, maintenance of access, control of directionality (i.e., steerability), and/or a combination of these factors. Steerable sheaths have broad uses in the body and peripheral far beyond their typical use in endovascular aortic work. Adoption of these techniques allows for improved safety, efficacy, and efficiency of several IR procedures.

Keywords

endovascular - procedures - embolization - therapeutic - thrombectomy - stents - foreign bodies

Introduction

Interventional radiology (IR) focuses on minimally invasive, image-guided treatments obviating surgery.[1] [2] IR physicians work across nearly all organ systems and commonly perform procedures inside arteries and veins. To perform such procedures, IRs are necessarily familiar with obtaining “access.” Access implies the ability to introduce devices stably, reliably, and safely into deeper structures via percutaneous approaches. Wires, catheters, and sheaths may come preshaped, unshaped, or even with shapable characteristics. Vascular sheaths are instrumental in providing stable access points through which to repetitively deploy devices.

Steerable sheaths such as TourGuide (Medtronic, Dublin, Ireland) have historically been marketed and used primarily for narrow indications. Available literature focuses on fenestrated endografts,[3] cardiac ablations,[4] and unique case reports like untying catheters percutaneously.[5] A recent literature review of steerable catheters also focused primarily on aortic disease.[6] However, the unique dynamic steerability of these sheaths can provide immense flexibility during a variety of vascular and nonvascular interventions. While curved sheaths can provide some of these benefits, the ability to shape a sheath in real-time provides essentially infinitely more angles for interventional stability and access. Smaller case reports have discussed the use of steerable sheaths in removing foreign bodies[7] and visceral cannulation for nonaortic work such as mesenteric stenting,[8] but a comprehensive case review has not yet been published.

In our practice, the TourGuide sheath is used in a variety of body IR interventions. This case series describes numerous scenarios where the TourGuide sheath saves time, improves procedural ease, and enhances intervention.

Materials and Methods

This retrospective case review was performed with Institutional Review Board approval. Health Insurance Portability and Accountability Act (HIPAA) compliant retrospective search of our institutional picture archiving and communication system was performed to identify IR procedures with the TourGuide sheath from 2019 to the current day. Cases are categorized and reviewed to show varying use cases.

Arterial Embolization

The TourGuide sheath improves stability of access for embolization, facilitating catheterization and delivery of interventional tools. In tortuous arterial anatomy, it can further eliminate classic issues such as “bucking.” As a result, we have found that the TourGuide sheath has markedly enhanced IR performance with embolization.

Prostate Artery Embolization

We present a 77-year-old man with benign prostatic hyperplasia presenting for prostate artery embolization (PAE) ([Fig. 1]). In PAE, a 6.5-French 55-cm TourGuide sheath is formed to sit on the aortic bifurcation. From here, conventional diagnostic catheters—we prefer a 5-French 100-cm angled taper glide catheter—are advanced into the contralateral hypogastric artery. From there, microcatheter cannulation and embolization are performed. Thereafter, in many patients, the TourGuide sheath can cannulate the ipsilateral hypogastric artery with the aid of a contralateral oblique imaging plane and angiographic roadmap, allowing for completion of embolization. In tortuous ipsilateral iliac arterial anatomy, a reverse curve catheter (e.g., SOS Omni) may be used to cannulate the ipsilateral hypogastric artery.

Fig. 1 Prostate artery embolization. (A) A 6.5-French TourGuide sheath (large arrow) is formed over the aortic bifurcation. An angled catheter (arrows) has been advanced into the left hypogastric artery and an angiogram has been performed. (B) Left prostate artery angiogram is shown (arrowheads). Embolization is then performed via a conventional microcatheter. (C) The TourGuide sheath (large arrow) has been formed at the origin of the right hypogastric artery, and a similar combination of angled catheter and microcatheter has been deployed to catheterize the right prostate artery. Embolization is performed (asterisks).

Arterial Coil Embolization

We present an 87-year-old man with a bleeding duodenal ulcer presenting for gastroduodenal artery embolization ([Fig. 2]). In visceral artery embolization, stable access enhances delivery of coils or plugs. In contrast, poor stability can result in loss of access, poor control of devices, and even complications such as off-target embolization. Furthermore, arterial angulations may be variable; a radial or brachial arterial approach may even need consideration. However, in most cases, a 6.5-French 55-cm TourGuide sheath can be deployed to obtain secure access with sheath angulation customized to the target vessel. From here, a conventional diagnostic catheter and/or microcatheters can be easily advanced for embolization.

Fig. 2 Arterial coil embolization. (A) Computed tomography angiogram (CTA) three-dimensional reconstruction shows severe aortoiliac tortuosity (outlined by line). (B) CTA sagittal reformat reveals downward orientation of celiac artery origin (arrowheads). (C) A 6.5-French TourGuide sheath (large arrow) at celiac artery origin, hockey catheter in gastroduodenal artery. Gastroduodenal artery angiogram demonstrates a small gastroduodenal artery pseudoaneurysm (arrows) which must be targeted for embolization. (D) Status post coil embolization (asterisks), there is no further flow to the gastroduodenal artery or to the pseudoaneurysm.

Interventional Oncology Embolization

We present a 70-year-old man with multicentric hepatocellular carcinoma undergoing treatment with yttrium-90 radioembolization ([Fig. 3]). Stability is particularly important when delivering high doses of intra-arterial radiation. Identical principles apply in related procedures such as transarterial chemoembolization. Furthermore, stenotic or acutely angled celiac arteries can present unique challenges for stable catheterization. In this example case, the patient presents with a downward-angled celiac artery with stenosis. During mapping angiography, an SOS-Omni catheter demonstrated limited stability. Therefore, on the day of radioembolization treatment, the TourGuide sheath was instead deployed at the celiac artery origin to ensure stable access. The TourGuide sheath has frequently facilitated our ability to perform complex cancer embolizations.

Fig. 3 Interventional oncology embolization. (A) Computed tomography angiogram sagittal reformat shows downward orientation and stenosis of celiac artery origin (arrowheads). (B) Mapping angiogram is performed with an SOS-Omni catheter (arrows). However, access proves to be tenuous. (C) For yttrium-90 treatment, a 6.5-French TourGuide sheath (large arrow) is placed at the celiac artery origin. Notice that a hockey catheter is able to be advanced to the proper hepatic artery for additional stability. (D) Yttrium-90 radioembolization is then performed via a microcatheter in the left hepatic artery (asterisks).

Bronchial Artery Embolization

We present a 78-year-old woman with chronic lung disease, hemoptysis, and bleeding from the right lung on bronchoscopy ([Fig. 4]). While most bronchial artery catheterization can be performed with conventional catheters (e.g., Mickelson), in certain instances, further stability may be required. For example, in this patient with extremely hypertrophied bronchial arteries, severe tortuosity prohibited microcatheter advancement. Customizing the angle of the TourGuide sheath to the shape of the bronchial artery takeoff allowed easy advancement of standard and microcatheter technology and subsequent embolization.

Fig. 4 Bronchial artery embolization. (A) Mickelson catheter angiography demonstrates hypertrophied right bronchial arteries (arrows). However, severe tortuosity and uncoiling at the origin prohibit microcatheter advancement. (B) A 6.5-French TourGuide sheath (large arrow) is placed into the origin of the right bronchial arteries. (C) The microcatheter is now able to be advanced with ease into the distal right bronchial artery branches (asterisks). (D) Successful catheterization of distal bronchial artery, which is severely hypertrophied (arrowheads). (E) Angiography status post particle embolization demonstrates significant flow reduction (brackets). There was resultant immediate resolution of hemoptysis.

Arterial Thrombectomy/Thrombolysis

Complex arterial intervention such as thrombectomy and thrombolysis can be complicated by arterial vascular tortuosity, angulation, and access issues. Traditional catheters and sheaths can be technically limited; the operator may need to obtain more than one access, perform more than one procedure, or choose an unfavorable access site. The TourGuide sheath can also simplify arterial intervention.

Arterial Thrombolysis

We present a 72-year-old man with an aortobifemoral bypass graft presenting with Rutherford IIA acute limb ischemia of the left lower extremity and was found to have complete thrombosis of the left limb of his bypass graft ([Fig. 5]). Anatomy of bypass grafts presents challenges for going “up and over.” Accessing the thrombosed limb directly would result in incomplete treatment. Therefore, the TourGuide sheath was deployed in a novel fashion to mimic an “up and over” approach by forming the curve at the graft bifurcation. Thrombolysis was successfully performed.

Fig. 5 Arterial thrombolysis. (A) Initial aortic angiogram shows occlusion of the left aortoiliac bypass graft limb (asterisks outline expected location of flow). (B) A 6.5-French TourGuide (large arrow) sheath is formed at and into the origin of the left bypass graft limb. The thrombosed segment is crossed, and arterial thrombolysis was performed with a thrombolysis catheter (arrowheads at radio-opaque markers). (C) Thrombolysis check angiogram on the following day demonstrates a widely patent bypass graft (bracket).

Arterial Thrombectomy

We present an 84-year-old woman with a history of atrial fibrillation presenting with acute-onset abdominal pain and was found to have thrombosis of the superior mesenteric artery ([Fig. 6]). The TourGuide sheath can secure access to acutely angled visceral arteries. In this case, the TourGuide sheath not only secured access within a difficult angle of the superior mesenteric artery but also served as a conduit for delivery of a thrombectomy catheter.

Fig. 6 Arterial thrombectomy. (A) Computed tomography angiogram sagittal reformat shows thrombus in the proximal superior mesenteric artery (arrows). (B) Angiogram shows thrombus within proximal and mid-superior mesenteric artery with no flow distally (arrowheads). (C) A 7-French TourGuide sheath (large arrow) is formed into the superior mesenteric artery origin. Thereafter, thrombectomy is pursued with a CAT7 and subsequently a CAT6 thrombectomy catheter (Penumbra, Alameda, California, United States (asterisks). (D) Completion angiogram with complete recanalization of the superior mesenteric artery and its branches (bracket).

Stenting/Recanalization

Recanalization of occluded or stenosed vessels, whether arteries or veins, can be technically challenging. Providing stable yet customized angles can typically improve pushability, which in turn enhances the ability to cross tough lesions. As such, the addition of the TourGuide sheath can not only improve probabilities of success but also speed up procedural time.

Venous Recanalization

We present a 29-year-old woman with chronic occlusion of the left common iliac vein ([Fig. 7]). In chronic venous occlusive disease, occlusions are extraordinarily difficult to cross in an antegrade fashion. For example, in this case, access from the left common femoral vein results in immediate passage into a dominant paraspinal collateral. In a fashion reminiscent of arterial work, the TourGuide sheath can be placed up and over the iliocaval bifurcation. From here, catheters and wires can be passed to cross the occluded iliac venous segments in a retrograde fashion, also reminiscent of peripheral artery work (e.g., pedal access, SAFARI technique, etc.). After flipping the access, the intervention can be completed.

Fig. 7 Venous recanalization. (A) Magnetic resonance imaging venogram image shows chronic occlusion of the left common and external iliac vein (arrows). (B) Supine venogram from a left common femoral vein access confirms chronic occlusion (asterisks outline the expected location of flow). Multiple attempts at retrograde crossing were unsuccessful despite numerous wires/catheters, likely due to drainage into a large, mature paraspinal venous collateral (bracket). (C) A 7-French TourGuide sheath (large arrow) is formed and placed over the iliocaval bifurcation from a right common femoral vein access. The catheter and wire were then used to cross the occlusion in a retrograde fashion. After crossing the occlusion, the wire is snared and externalized (arrowheads). Thereafter, the wire and catheter are redirected into the inferior vena cava with ease. (D) After placement of a 14 mm × 10 cm Abre (Medtronic, Minneapolis, Minnesota, United States) stent, venogram shows complete recanalization of the left common and external iliac veins (outlined by line).

Visceral Arterial Stenting

We present a 94-year-old man with worsening abdominal pain, diarrhea, and weight loss, who was found to have severe arterial stenoses of the celiac artery and superior mesenteric artery ([Fig. 8]), and was brought in for visceral angiography and stenting. In the past, certain angles, stenoses, and/or occlusions of visceral arteries meant that brachial arterial access could become mandatory. In our practice, the adoption of the TourGuide sheath has liberalized the ability to perform nearly all complex visceral arterial interventions from a common femoral access, including the delivery of stents. Arteries most commonly treated include the celiac artery, superior mesenteric artery, and renal arteries.

Fig. 8 Visceral arterial stenting. (A) Mesenteric artery duplex reveals critical stenosis of superior mesenteric artery with significant elevated velocities (arrows). Similar findings are noted in the celiac artery (not shown). (B) CTA sagittal reformat reveals critical stenoses of both celiac and superior mesenteric artery origins with immediate reconstitution (arrowheads). (C) Aortic angiogram shows a critical stenos is of the celiac artery (two asterisks) and no visible flow into the superior mesenteric artery (single asterisk). (D) A 7-French TourGuide sheath is (large arrow) used to engage the superior mesenteric artery in preparation for intervention. Ultimately, a 7 × 18 mm arterial vascular stent is placed and the superior mesenteric artery is recanalized (outlined by line). (E) A 7-French TourGuide sheath (white arrow) is used to engage the celiac artery in preparation for intervention. An 8 mm × 29 mm vascular stent is placed to successfully treat the celiac artery stenosis (outlined by line).

Urinary Intervention

The urinary system presents unique challenges for IR, typically because of unfavorable angulations relative to access points. For example, from a nephrostomy access, the angle into the ureters is often acute. Introduction of steerable sheaths into urinary intervention may increase flexibility and technical success of complex intervention.

Complex Percutaneous Nephrolithotomy Access

We present a 73-year-old woman with a left renal staghorn calculus, for which a nephroureteral access is desired for percutaneous nephrolithotomy ([Fig. 9]). While most can be performed with conventional catheters, more directionality and pushability may become required. The TourGuide sheath is a consideration in the management of such complex cases, as it has more body than a catheter and can be used to direct the catheter and wire dynamically.

Fig. 9 Complex percutaneous nephrolithotomy access. (A) Computed tomography (CT) coronal reformat shows a staghorn calculus in the left kidney, which is the target for percutaneous nephrolithotomy by urology (arrows). (B) Prone percutaneous access to the left renal pelvis is obtained, but all wire and catheter maneuvers fail. Furthermore, these maneuvers simply result in perforation and contrast extravasation into the retroperitoneum (brackets). (C) A 6.5-French TourGuide sheath (large arrow) is placed into the renal pelvis to provide torque and driveability. Thereafter, wires and catheters are able to be passed into the bladder with ease (asterisks). (D) Two catheters are left from the skin to the kidney for operative access (arrowheads). (E) CT scan status post percutaneous nephrolithotomy demonstrates successful and complete stone removal, made possible by the complex access obtained in interventional radiology.

Ureteral Stent Retrieval/Manipulation

We present an 80-year-old man with a renal pelvis defect and ureteral disruption with urinoma after a partial nephrectomy ([Fig. 10]). While the exact pathology presented in this case is particularly unique, this case demonstrates the unique flexibility of the TourGuide sheath in the manipulation of internal objects within the human body from a percutaneous access. In this case, the urologist obtained cystoscopic access and placed a wire into the ureter and into the region of the renal pelvis defect. Only with the deployment of the TourGuide sheath was this wire able to be snared and then pulled into the true ureteral and renal pelvis lumen, after which a nephroureteral stent was successfully placed. Building on principles from this case, in our practice, we have used the TourGuide sheath in many urinary cases, including the management of encrusted stents, malpositioned stents, fractured catheters, and foreign bodies.

Fig. 10 Ureteral stent retrieval/manipulation. (A) Computed tomography (CT) axial image shows left renal mass (arrows). (B) CT axial image after partial nephrectomy shows a left renal parenchymal defect, contrast extravasation, and urinoma formation (brackets). (C) CT sagittal reformat shows contrast passing through the known defect in the renal pelvis (arrowhead). (D) Percutaneous and transurethral bladder access is obtained. Wire is passed from the cystoscopic access by the urologist, but it was unable to be snared using a conventional sheath. The wire was suspected to be in the retroperitoneal urinoma given its orientation and position. After placing a 6.5-French TourGuide sheath (large arrow), a vascular snare was finally able to capture the wire (asterisks). (E) After pulling the wire taut, stable wire access is obtained within the injured renal pelvis and ureter. Over the wire, a percutaneous nephroureteral catheter is placed. At this time, there remains a large extraluminal contrast extravasation in keeping with urinoma (brackets). (F) At 2 months, the patient is brought back for nephrostogram. This shows that the renal pelvis and ureteral leak as well as the urinoma have resolved. Ultimately, the stent was able to be removed.

Foreign Body Retrieval

As a specialty that regularly manages various catheters, stents, and devices, IR is uniquely positioned to capture and remove foreign bodies. Regular tools of the trade usually include vascular sheaths, guide catheters, and snares; none has the ability to create dynamic angles. Introduction of the TourGuide sheath in our practice has entirely changed the way in which most foreign bodies are addressed.

Malpositioned Ureteral Stent Repositioning

We present a 67-year-old man who underwent operative placement of a ureteral diversion stent to help heal a neobladder ([Fig. 11]). Initially, both stents terminated percutaneously at the skin surface. However, the left stent slipped back into the abdomen and was free-floating within the peritoneal cavity. The TourGuide sheath was necessary to “fish” for the end of the ureteral stent. The ability to actively torque and angle the tip of the TourGuide sheath allows capture and externalization of the malpositioned stent, obviating a return to the operating room.

Fig. 11 Malpositioned ureteral stent repositioning. (A) The lateral image demonstrates a percutaneous diversionary stent that has lapsed or fallen into the peritoneum. A 6.5-French TourGuide (large arrow) has been used to direct a vascular snare and has successfully captured the tip of the stent (asterisks). (B) Lateral image captures the catheter being pulled out of the anterior abdominal wall to reposition it percutaneously (arrows), allowing urinary diversion and appropriate healing of the urologic operative site. (C) Fluoroscopy image demonstrates the catheter (once outside the skin) being secured with external forceps prior to being tied into place by urology (arrowheads).

Complex Inferior Vena Cava Filter Removal

We present a 53-year-old woman with an inferior vena cava (IVC) filter who presents for IVC filter removal ([Fig. 12]). In this case, the IVC filter could not be removed using the conventional snare technique due to tissue overgrowth along the recapture hook. We have historically used rigid endobronchial forceps in these cases; however, these were not available. Instead, the Raptor endoscopic grasping device (Steris, Mentor, Ohio, United States) was used; however, the Raptor device is not steerable. An 8.5-French TourGuide sheath can be used to angle the Raptor toward the IVC filter. In contrast with endobronchial forceps, this dynamic maneuver improves the ability to capture the filter. In conjunction with Raptor's stronger bite force, this has become a leading technique in our practice for complex IVC filter retrieval.

Fig. 12 Complex inferior vena cava filter removal. (A) Frontal view of a 7-French TourGuide sheath (large arrow) directing the Raptor device (arrowhead) to a right-lateral position within inferior vena cava (IVC), allowing for capture of the IVC filter tip. (B) Lateral view of a 7-French TourGuide sheath (large arrow) and the Raptor device (arrowhead) capturing the IVC filter tip. (C) Frontal view of successful IVC filter removal, as the filter is being removed in the sheath (arrows). (D) Lateral view of successful IVC filter removal (bracket).

Discussion

In this case series, we presented several distinct uses of the TourGuide sheath in a variety of IR uses in the body and periphery. There are a variety of applications such as embolization procedures, arterial thrombectomy, arterial thrombolysis and thrombectomy, arterial recanalization and stenting, urinary procedures, and foreign body retrievals. In these various use cases, the TourGuide sheaths were found to provide enhanced stability of access, improved pushability, maintenance and management of access, control of directionality (i.e., steerability), and/or a combination of these factors, as summarized in [Table 1]. Steerable sheaths have broad uses in the body and peripheral far beyond their typical use in endovascular aortic work. Adoption of these techniques allows for improved safety, efficacy, and efficiency of several IR procedures.

Table 1

Category	Procedure type	Anatomy	Use cases
Arterial embolization	Prostate artery embolization	Aortoiliac bifurcation and hypogastric artery	Increases stability of access for difficult catheterizations
	Arterial coil embolization	Various; commonly visceral	• Tackles acute arterial angulations • Improves stability for delivering coils
	Interventional oncology embolization	Celiac artery	Improves stability for delivering embolics, particularly in visceral tortuosity
	Bronchial artery embolization	Bronchial artery	Provide flexible angles of access to optimize cannulation
Arterial thrombectomy/thrombolysis	Arterial thrombolysis	Various; commonly visceral or lower extremity	Tackle atypical access or angulations, such as bypass grafts
	Arterial thrombectomy	Various; commonly visceral	• Deliver thrombectomy tools even in acutely angled target vessels such as mesenteric arteries • Avoid higher-risk access such as brachial artery
Stenting/recanalization	Venous recanalization	Various; commonly iliocaval	• Deliver novel angles and access for crossing occlusions, such as “up and over” • Avoid second sticks or flipping patient from prone-to-supine
	Visceral arterial stenting	Celiac artery, superior mesenteric artery	• Customized angles and direction for recanalization • Stable access for balloon and stent delivery • Avoid higher-risk access such as brachial artery
Urinary intervention	Complex percutaneous nephrolithotomy access	Kidney	Enhanced pushability and customized angles for providing access past occlusive renal pelvis stones
	Ureteral stent retrieval/manipulation	Kidney/bladder	Full manipulation of tools inside a body cavity such as an operative defect or bladder
Foreign body retrieval	Malpositioned ureteral stent repositioning	Various	Full manipulation of tools inside a body cavity such as the peritoneal cavity
	Complex inferior vena cava filter removal	Inferior vena cava	Obtain full control of unsteerable devices to allow novel techniques for inferior vena cava filter retrieval

Conclusion

Application of the TourGuide sheath in body and peripheral intervention creates many novel and unique opportunities to improve the safety, efficiency, and efficacy of IR intervention.

Conflict of Interest

Dr. Alexander S. Misono reported a research grant from SinglePass and Stryker/Inari Medical. Consulting fees received from AIDoc, Argon Medical, MediView, Medtronic, Merit Medical, Penumbra, SinglePass, Sirtex, Stryker/Inari Medical, Terumo, TriSalus, and Vasorum. Payment or honoraria received from AIDoc, Argon Medical, MediView, Medtronic, Merit Medical, SinglePass, Sirtex, Stryker/Inari Medical, TriSalus, and Vasorum. Direct support for attending meetings and/or travel from Argon Medical, Medtronic, Merit Medical, Penumbra, SinglePass, Sirtex, Stryker/Inari Medical, Terumo, and TriSalus.

Stock options with SinglePass. All other authors report no conflict of interest.

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Artikel online veröffentlicht:
21. November 2025