Coronary Sinus Lead Extraction

Antidromic snare technique for re-implantation of a coronary sinus lead into the same cardiac vein after transvenous lead extraction: a case report

Background

After coronary sinus (CS) lead extraction in patients with cardiac resynchronization therapy (CRT), occlusion of the branch vessel from which CS lead was extracted is a major obstacle to re-implantation, particularly if that vessel is the only optimal vessel for resynchronization.

Case summary

A 75-year-old female who underwent CRT implantation 11 years prior presented with worsening dyspnoea, right ventricle-only pacing rhythm, and increased CS lead pacing threshold. Because she was a CRT responder, we decided to replace the malfunctioning CS lead. After successful extraction, the vessel from which CS lead was extracted was not visualized, and guidewire re-insertion attempts failed. No other branch vessels suitable for re-implantation were observed. Fortunately, distal portion of the target vessel was viewed by a retrograde flow of contrast. A guidewire was advanced retrograde into the target vein via a connecting vessel, and the distal end of the guidewire was snared around CS ostium and then pulled out of the sheath. A new CS lead was inserted through the distal end of the guidewire and successfully implanted antegrade into the same target vein using a veno-venous loop of the guidewire ('anti-dromic snare technique'). The patient was discharged 2 days after the procedure without complications.

Discussion

Antegrade re-implantation of CS lead may not be possible after extracting CS leads with long dwell times, possibly due to extraction-induced vessel occlusion. If the occluded vessel is the only proper vessel for CS lead re-implantation, the anti-dromic snare technique could be a safe and effective bail-out strategy.

Coronary Venous Lead Extraction

The increasing number of cardiac resynchronization therapy devices implanted, coupled with the increasing incidence of cardiac implantable electronic device infection, has led to a greater need for extraction of coronary venous pacing leads. The objectives of this study were to review the indications, techniques and published results of coronary venous lead extraction. In this study, we searched PubMed using the search terms "lead extraction," "coronary sinus," "coronary venous," "pacing," and "cardiac resynchronization therapy" for relevant papers. The reference lists of relevant articles were also searched, and personal experience was drawn upon. Published success rates and complications were found to be similar to those reported for non-coronary venous leads in experienced centers. However, reimplantation success differs and can be limited by vessel occlusion postextraction. The available active fixation coronary sinus lead (Attain Starfix™; Medtronic, MN, USA) is a particularly complex lead to extract, whereas limited data on the newer active fixation leads (Attain Stability™, Medtronic, MN, USA) suggest that they are less challenging to remove. The study concluded that coronary venous lead extraction presents unique challenges, especially reimplantation, that require special consideration and planning to overcome.

A Case of Arterial and Venous Tear during Single Lead Extraction

Transcutaneous lead extraction can be associated with significant morbidity and mortality. The risk of causing concomitant arterial and venous injury is rare. We report a case of marginal artery rupture with coronary sinus rupture after a CS lead extraction. A 71-year-old male was admitted for extraction of a 6-year-old implantable cardioverter-defibrillator lead due to fracture from insulation break. During the lead extraction, blood pressure fell precipitously and echocardiographic findings were consistent with pericardial effusion. After unsuccessful pericardiocentesis, open chest sternotomy and evacuation of hematoma was performed. Subsequent surgical repair of several injuries was completed including the distal coronary sinus, a large degloving injury of posterior portion of the heart, and first obtuse marginal branch bleed. This case demonstrates that when performing transcutaneous lead extraction (TLE) with laser sheath, a degloving injury can cause arterial rupture with concomitant coronary sinus injury. A multidisciplinary team-based approach can ensure patient safety. Learning Objective. Implantable cardioverter-defibrillator leads will falter over time. With the advancement of new technology for extraction more frequent and serious complications will occur. Active fixation CS leads present unique challenges. In the presence of hemodynamic changes during extraction the occurrence of both an arterial and venous injury must be considered.