Beyond the Valve: A Tailored Distal Snaring Strategy for Complex Arterial and Venous Nose Cone Entrapment During Transfemoral TAVI and TricValve Implantation.

Nose cone entrapment is a rare but potentially serious complication of structural heart interventions. Most cases have been reported during transcatheter aortic valve implantation (TAVI), typically related to heavy left ventricular outflow tract (LVOT) calcification, severe annular angulation, or under-expansion of the valve frame. Entrapment within vascular structures is much less common. We describe two unusual cases. The first involved femoral artery entrapment of the Evolut PRO+ nose cone due to a ProGlide suture knot, managed with a distal snaring technique but complicated by vascular injury requiring covered stent implantation. The second occurred during heterotopic caval valve implantation (TricValve system), in which interference from a prominent Eustachian valve was suspected to have contributed to venous entrapment and dislodgement of the delivery system nose cone. This was successfully retrieved en bloc with an EN Snare without vascular complications. These cases highlight that nose cone entrapment is not limited to valvular structures and may also occur in arterial or venous vasculature, with different mechanisms and bailout strategies.