Contemporary Pacemaker and ICD Lead Management
The majority of leads are extracted through the vein through which the lead was implanted. Bongiorni et al. have described high success of extraction using multiple venous sites. In this approach, the lead is drawn initially into the IVC using a tip deflecting wire. It is then captured a second time using a Lasso introduced through the internal jugular vein to apply traction along the direction of the lead as it passes down the SVC and through the tricuspid valve. Extractors should be particularly familiar with the femoral venous approach, which is often used to rescue free floating leads.
Lead extraction through the femoral vein is commonly performed as a rescue procedure when the lead is inaccessible from the vein of implantation, for disrupted leads with free floating ends and for leads that cannot be freed from the endocardium. Hence, it is not surprising that the use of this approach increased with longer implantation times: 5, 11, 20 and 31%, respectively, in leads that are <1, 1–3, 4–7 and ≥8 years old in one series. This approach can also be used when there is excessive venous scar or due to operator preference. A retrospective comparison of the femoral approach with laser sheath for extraction of older leads showed similar efficacy and complication rates for both. The femoral approach was, however, associated with longer procedural and fluoroscopy times. Since traction is applied from an inferior approach (also dubbed 'indirect traction'), the femoral approach is thought to have lower propensity for perforation, venous tear and cardiac avulsion. There are a number of tools currently available for femoral lead extraction, including the Byrd Femoral Work Station (Cook Vascular). The Byrd Femoral Work Station comes prepackaged with a 30-cm long, 16-Fr venous sheath that acts as the work station and 12-Fr inner sheath, preloaded with tip-deflecting wire and Dotter retriever snare. Other equipment that is often used include needle eye's snare, loop snare, Amplatz goose neck snare and pigtail catheter (Figure 5).
(Enlarge Image)
Figure 5.
Snares used for femoral lead extraction. (A) Lead-deflecting wire and Dotter basket, (B) loop snare and (C) needle's eye snare.
The basic approach varies based on whether the lead tip has been freed or not. If the lead tip has been freed, the femoral venous sheath is positioned in the right atrium. The lead is amputated proximally at the venous entry site. The free end is snared in the right atrium or in the IVC after pulling the lead into the IVC. It can now be removed by traction (Figure 6A). If the lead tip is still attached to the endocardium, the femoral venous sheath is positioned in the right atrium and a loop of the lead is snared and brought into the sheath. The proximal end is amputated, and the lead tip freed with traction and countertraction (Figure 6B). Both the techniques involve some form of snaring device. It is important to ensure that when the lead is snared, the process should be kept reversible. If the lead is grabbed but cannot be reversed, thoracotomy may be required to remove the lead and the extraction device.
(Enlarge Image)
Figure 6.
Femoral venous lead extraction. (A) The lead tip has been freed, and the free end is snared in the right atrium from the femoral approach. Traction can now be used to remove the lead. (B) The lead tip is still adherent to the endocardium. A loop of the lead is snared in the right atrium, and lead tip freed by traction and countertraction.
One of the authors (SJ Asirvatham) has from a personal perspective noted an evolution in the need for operators to be conversant with femoral extraction techniques. Two decades ago, femoral extraction was an essential skill for extractionists, but with increasing familiarity and facility with powered sheaths, this has become less commonly required. In the near future, however, with the potential introduction of leadless devices, snaring techniques may again be an important requirement in the lead-management physician's invasive armamentarium once again.
In the current environment, surgical extraction by thoracotomy is usually reserved for larger vegetations or for cases where surgical intervention is required for other reasons (e.g., valve repair). Concerns regarding vegetation size and the risk of embolization in the lungs are varied between institutions but is typically considered for vegetations greater than 2 cm. A limited thoracotomy may also be useful for the placement of epicardial leads in some cases where there is systemic infection.
Approach to Extraction
Lead Entry Site Venous Approach
The majority of leads are extracted through the vein through which the lead was implanted. Bongiorni et al. have described high success of extraction using multiple venous sites. In this approach, the lead is drawn initially into the IVC using a tip deflecting wire. It is then captured a second time using a Lasso introduced through the internal jugular vein to apply traction along the direction of the lead as it passes down the SVC and through the tricuspid valve. Extractors should be particularly familiar with the femoral venous approach, which is often used to rescue free floating leads.
Femoral Approach
Lead extraction through the femoral vein is commonly performed as a rescue procedure when the lead is inaccessible from the vein of implantation, for disrupted leads with free floating ends and for leads that cannot be freed from the endocardium. Hence, it is not surprising that the use of this approach increased with longer implantation times: 5, 11, 20 and 31%, respectively, in leads that are <1, 1–3, 4–7 and ≥8 years old in one series. This approach can also be used when there is excessive venous scar or due to operator preference. A retrospective comparison of the femoral approach with laser sheath for extraction of older leads showed similar efficacy and complication rates for both. The femoral approach was, however, associated with longer procedural and fluoroscopy times. Since traction is applied from an inferior approach (also dubbed 'indirect traction'), the femoral approach is thought to have lower propensity for perforation, venous tear and cardiac avulsion. There are a number of tools currently available for femoral lead extraction, including the Byrd Femoral Work Station (Cook Vascular). The Byrd Femoral Work Station comes prepackaged with a 30-cm long, 16-Fr venous sheath that acts as the work station and 12-Fr inner sheath, preloaded with tip-deflecting wire and Dotter retriever snare. Other equipment that is often used include needle eye's snare, loop snare, Amplatz goose neck snare and pigtail catheter (Figure 5).
(Enlarge Image)
Figure 5.
Snares used for femoral lead extraction. (A) Lead-deflecting wire and Dotter basket, (B) loop snare and (C) needle's eye snare.
The basic approach varies based on whether the lead tip has been freed or not. If the lead tip has been freed, the femoral venous sheath is positioned in the right atrium. The lead is amputated proximally at the venous entry site. The free end is snared in the right atrium or in the IVC after pulling the lead into the IVC. It can now be removed by traction (Figure 6A). If the lead tip is still attached to the endocardium, the femoral venous sheath is positioned in the right atrium and a loop of the lead is snared and brought into the sheath. The proximal end is amputated, and the lead tip freed with traction and countertraction (Figure 6B). Both the techniques involve some form of snaring device. It is important to ensure that when the lead is snared, the process should be kept reversible. If the lead is grabbed but cannot be reversed, thoracotomy may be required to remove the lead and the extraction device.
(Enlarge Image)
Figure 6.
Femoral venous lead extraction. (A) The lead tip has been freed, and the free end is snared in the right atrium from the femoral approach. Traction can now be used to remove the lead. (B) The lead tip is still adherent to the endocardium. A loop of the lead is snared in the right atrium, and lead tip freed by traction and countertraction.
One of the authors (SJ Asirvatham) has from a personal perspective noted an evolution in the need for operators to be conversant with femoral extraction techniques. Two decades ago, femoral extraction was an essential skill for extractionists, but with increasing familiarity and facility with powered sheaths, this has become less commonly required. In the near future, however, with the potential introduction of leadless devices, snaring techniques may again be an important requirement in the lead-management physician's invasive armamentarium once again.
Surgical Removal
In the current environment, surgical extraction by thoracotomy is usually reserved for larger vegetations or for cases where surgical intervention is required for other reasons (e.g., valve repair). Concerns regarding vegetation size and the risk of embolization in the lungs are varied between institutions but is typically considered for vegetations greater than 2 cm. A limited thoracotomy may also be useful for the placement of epicardial leads in some cases where there is systemic infection.
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