Simultaneous lead traction from above and below: A novel technique to reduce the risk of superior vena cava injury during transvenous lead extraction

Traditional and Non-traditional Lead Extraction Techniques

With increasing volume of cardiac implantable electronic devices in the last decade, the indications for device extraction have increased. Multidisciplinary collaboration between cardiothoracic surgeons, cardiac anesthesiologists, and cardiac electrophysiologists has been recognized as an essential pre-requisite in pre-procedural planning to limit complications from this inherently risky procedure. Fortunately, the tools and techniques have continued to evolve to make extraction safer and more effective. This article discusses traditional and non-traditional techniques for transvenous lead extraction in addition to retrieval of leadless pacemakers.

Preoperative and Intraoperative Imaging during Transvenous Lead Extraction

Transvenous lead extraction is performed for device infection, lead failure, or to provide access for additional leads/device upgrade. A patient-centered risk assessment for transvenous lead extraction can be determined using a combination of clinical factors and several imaging modalities. Predicting a complex lead extraction, for example, one that will require powered tools or the use of a femoral approach, is aided by pre-procedural imaging and clinical assessment. Procedural imaging utilizing fluoroscopy, transesophageal echocardiography, and intracardiac echocardiography during an extraction can improve safety and identify complications rapidly.

Lead Extraction History, Training, Volume, and Location

Transvenous lead extraction (TLE) has evolved significantly since the introduction of cardiac pacing systems in the 1950s. The need for TLE has grown due to the increasing complexity of cardiac devices and patients, alongside rising infection rates and regulatory recalls. Despite its challenges, improved institutional support and advanced training programs have made TLE more accessible. Modern TLE indications are well-defined, evolving through scientific statements to include comprehensive lead management best practices and safety protocols. However, underutilization persists, particularly in infection management, highlighting the need for continued education and adherence to guidelines.

Evaluation of tricuspid valve regurgitation following transvenous rotational mechanical lead extraction

AIMS

Transvenous lead extraction (TLE) is potentially complicated by significant tricuspid valve regurgitation increase (TRI). However, there are limited data on the effect of the bidirectional rotational mechanical sheaths on significant TRI. The aim of the present study was to investigate the rate of significant changes in tricuspid regurgitation (TR) severity following mechanical rotational TLE and their outcomes.

METHODS AND RESULTS

In 158 patients (mean age 66 ± 16.9 years) undergoing mechanical rotational TLE, acute changes in TR severity were assessed by echocardiography evaluation. A significant acute TRI was defined as an increase of at least one grade with a post-extraction severity at least moderate. A total of 290 leads were extracted (mean implant duration, 93 ± 65 months). Significant TRI was noted in 5.7% of patients, and it was linked to tricuspid valve damage, TLE infection indication, and longer lead implant duration. Univariate predictors of significant TRI included implant duration of all leads [odds ratio (OR) 1.01; 95% confidence interval (CI) 1.003-1.018; P = 0.001] and right ventricular leads (OR 1.01; 95% CI 1.004-1.017; P = 0.002). Severe increase of TR following TLE was an independent predictor of mortality [hazard ratio (HR) 5.20; 95% CI 1.44-18.73; P = 0.012 ] along with severe systolic dysfunction (HR 2.37; 95% CI 1.01-5.20; P = 0.032), and systemic infection (HR 2.28; 95% CI 1.06-4.89; P = 0.035).

CONCLUSION

Significant TRI was detected in 5.7% of patients following transvenous rotational mechanical lead extraction. The duration of lead implantation emerged as the sole predictor of significant TRI. Physicians engaged in TLE should exercise greater vigilance for this potential complication.

Transvenous lead extraction: Experience of the Tandem approach

AIMS

Transvenous lead extraction (TLE) is important in the management of cardiac implantable electronic devices but carries risk. It is most commonly completed from the superior access, often with 'bail-out' support via the femoral approach. Superior and inferior access may be used in tandem, which has been proposed as an advance in safety and efficacy. The aim of this study is to evaluate the safety and efficacy of the Tandem approach.

METHOD

The 'Tandem' procedure entailed grasping of the targeted lead in the right atrium to provide countertraction as a rotational dissecting sheath was advanced over the lead from the subclavian access. Consecutive 'Tandem' procedures performed by a single operator between December 2020 and March 2023 in a single large-volume TLE centre were included and compared with the conventional superior approach (control) using 1:1 propensity score matching; patients were statistically matched for demographics.

RESULTS

The Tandem in comparison with the conventional approach extracted leads of much greater dwell time (148.9 ± 79 vs. 108.6 ± 77 months, P < 0.01) in a shorter procedure duration (96 ± 36 vs. 127 ± 67 min, P < 0.01) but requiring more fluoroscopy (16.4 ± 10.9 vs. 10.8 ± 14.9 min, P < 0.01). The Tandem and control groups had similar clinical (100% vs. 94.7%, P = 0.07) and complete (94.8% vs. 92.8%, P = 0.42) success, with comparable minor (4% vs. 6.7%, P = 0.72) and major (0% vs. 4%, P = 0.25) complications; procedural (0% vs. 1.3%, P = 1) and 30-day (1.3% vs. 4%, P = 0.62) mortality were also similar.

CONCLUSION

The Tandem procedure is as safe and effective as the conventional TLE. It can be applied to leads of a long dwell time with a potentially shorter procedure duration.

Comparison of non-laser and laser transvenous lead extraction: a systematic review and meta-analysis

AIMS

Transvenous lead extraction (TLE) is performed using non-laser and laser techniques with overall high efficacy and safety. Variation in outcomes between the two approaches does exist with limited comparative evidence in the literature. We sought to compare non-laser and laser TLE in a meta-analysis.

METHODS AND RESULTS

We searched Medline, Embase, Scopus, ClinicalTrials.gov, and CENTRAL databases for TLE studies published between 1991 and 2021. From the included 68 studies, safety and efficacy data were carefully evaluated and extracted. Aggregated cases of outcomes were used to calculate odds ratio (OR), and pooled rates were synthesized from eligible studies to compare non-laser and laser techniques. Subgroup comparison of rotational tool and laser extraction was also performed. Non-laser in comparison with laser had lower procedural mortality (pooled rate 0% vs. 0.1%, P < 0.01), major complications (pooled rate 0.7% vs. 1.7%, P < 0.01), and superior vena cava (SVC) injury (pooled rate 0% vs. 0.5%, P < 0.001), with higher complete success (pooled rate 96.5% vs. 93.8%, P < 0.01). Non-laser comparatively to laser was more likely to achieve clinical [OR 2.16 (1.77-2.63), P < 0.01] and complete [OR 1.87 (1.69-2.08), P < 0.01] success, with a lower procedural mortality risk [OR 1.6 (1.02-2.5), P < 0.05]. In the subgroup analysis, rotational tool compared with laser achieved greater complete success (pooled rate 97.4% vs. 95%, P < 0.01) with lower SVC injury (pooled rate 0% vs. 0.7%, P < 0.01).

CONCLUSION

Non-laser TLE is associated with a better safety and efficacy profile when compared with laser methods. There is a greater risk of SVC injury associated with laser sheath extraction.

Wire ThRoUgh Snare Twice (Wire TRUST) technique: A novel method to grasp a lead with inaccessible ends as a supportive femoral approach for transvenous lead extraction

INTRODUCTION

Transvenous lead extraction (TLE) is a crucial procedure for managing cardiac implantable electronic devices. The use of a combined superior and femoral approach has been found to enhance the success rate of TLE. This report introduces a novel technique, named "Wire ThRoUgh Snare Twice" (Wire TRUST), for effectively grasping a lead without a free end during TLE.

METHOD

The Wire TRUST technique was applied in a case involving a 49-year-old male patient requiring TLE due to electrical artifact on the right ventricular (RV) lead, replacement of the RV lead, and pacemaker generator exchange. The Wire TRUST technique involved the insertion of a 4-Fr pigtail catheter and a 6-Fr snare catheter through the 14-Fr sheath inserted from the right common femoral vein. The 4-Fr pigtail catheter was hooked to the RV lead under multidirectional fluoroscopic guidance in the right atrium. The 0.014-in. guidewire was advanced through the pigtail catheter, crossing the RV lead until reaching the inferior vena cava. Subsequently, the distal end of the 0.014-in. guidewire was captured using a snare and pulled, facilitating externalization of the guidewire. After externalization, both ends of the 0.014-in. guidewire were passed through the snare outside the body and reinserted into the 14-Fr sheath. By simultaneously advancing and closing the snare while applying tension to the 0.014-in. guidewire, a secure grip on the lead without free ends was achieved.

RESULTS

The Wire TRUST technique enabled successful lead extraction and replacement without any complications. The technique facilitated the co-axial alignment of the powered sheath with the RV lead, ensuring safe and efficient extraction.

CONCLUSION

The Wire TRUST technique presents a novel and effective approach for grasping leads with inaccessible ends during TLE.

Transvenous Lead Extraction: Work in Progress

Cardiac implantable electronic devices are the cornerstone of cardiac rhythm management, with a significant number of implantations annually. A rising prevalence of cardiac implantable electronic devices coupled with widening indications for device removal has fuelled a demand for transvenous lead extraction (TLE). With advancement of tools and techniques, the safety and efficacy profile of TLE has significantly improved since its inception. Despite these advances, TLE continues to carry risk of significant complications, including a superior vena cava injury and mortality. However, innovative approaches to lead extraction, including the use of the jugular and femoral accesses, offers potential for further gains in safety and efficacy. In this review, the indications and risks of TLE are discussed while examining the evolution of this procedure from simple traction to advanced methodologies, which have contributed to a significant improvement in safety and efficacy.

Superior vena cava tear during transvenous lead extraction: Medical management in hemodynamically stable patients

INTRODUCTION

Superior vena cava (SVC) tear is the most lethal complication during transvenous lead extraction (TLE) with a mortality rate as high as 50%. Treatment involves aggressive attempts to maintain cardiac output and immediate sternotomy to localize and repair the vascular tear. Occlusion balloons have been developed to provisionally occlude the lacerated SVC and to provide hemodynamic stability allowing time for surgery. In case of mediastinal hematoma without hemodynamic instability, the strategy remains unclear.

METHODS AND RESULTS

We describe two cases of SVC tear during TLE. The first case was a 60-year-old man who presented with a right ventricular single-chamber defibrillator lead fracture and innominate vein stenosis. The RV lead was removed using a laser sheath causing a mediastinal hematoma with no active bleeding during surgical exploration few hours later. The second case was a 28-year-old man that presented with a right atrial (RA) lead fracture and RV lead insulation failure in a dual-chamber defibrillator (ICD).

CONCLUSION

Both the RA and RV leads were removed with mechanical sheaths, and a mediastinal hematoma was medically managed.

Intracardiac echocardiography Chinese expert consensus

In recent years, percutaneous catheter interventions have continuously evolved, becoming an essential strategy for interventional diagnosis and treatment of many structural heart diseases and arrhythmias. Along with the increasing complexity of cardiac interventions comes ever more complex demands for intraoperative imaging. Intracardiac echocardiography (ICE) is well-suited for these requirements with real-time imaging, real-time monitoring for intraoperative complications, and a well-tolerated procedure. As a result, ICE is increasingly used many types of cardiac interventions. Given the lack of relevant guidelines at home and abroad and to promote and standardize the clinical applications of ICE, the members of this panel extensively evaluated relevant research findings, and they developed this consensus document after discussions and correlation with front-line clinical work experience, aiming to provide guidance for clinicians and to further improve interventional cardiovascular diagnosis and treatment procedures.

Tricuspid Valve Damage Related to Transvenous Lead Extraction

BACKGROUND

Damage to the tricuspid valve (TVD) is now considered either a major or minor complication of the transvenous lead extraction procedure (TLE). As yet, the risk factors and long-term survival after TLE in patients with TVD have not been analyzed in detail.

METHODS

This post hoc analysis used clinical data of 2631 patients (mean age 66.86 years, 39.64% females) who underwent TLE procedures performed in three high-volume centers. The risk factors and long-term survival of patients with worsening tricuspid valve (TV) function after TLE were analyzed.

RESULTS

In most procedures (90.31%), TLE had no negative influence on TV function, but in 9.69% of patients, a worsening of tricuspid regurgitation (TR) to varying degrees was noted, including significant dysfunction in 2.54% of patients. Risk factors of TLE relating to severe TVD were: TLE of pacing leads (5.264; p = 0.029), dwell time of the oldest extracted lead (OR = 1.076; p = 0.032), strong connective scar tissue connecting a lead with tricuspid apparatus (OR = 5.720; p < 0.001), and strong connective scar tissue connecting a lead with the right ventricle wall (OR = 8.312; p < 0.001). Long-term survival (1650 ± 1201 [1-5519] days) of patients with severe TR was comparable to patients without tricuspid damage related to TLE.

CONCLUSIONS

Severe tricuspid valve damage related to TLE is relatively rare (2.5%). The main risk factors for the worsening of TV function are associated with a longer lead dwell time (more often the pacing lead), causing stronger connective tissue scars connecting the lead to the tricuspid apparatus and right ventricle. TVD is unlikely to affect long-term survival after TLE.

Is cardiopulmonary bypass standby still required for laser lead extractions?

Objective

Over the last two decades there has been an increase in the number of cardiac implantable electronic devices and consequently, there has also been an increased need for lead extractions. Fibrotic attachments develop between the lead and the venous and cardiac structures that may require the use of a laser to mobilize the lead. Cardiothoracic surgeons (CTS) have traditionally provided backup for surgical emergencies for these extractions. This study evaluates the surgical outcomes of patients undergoing transvenous laser lead extractions (TLE) and determines if CTS are still needed for backup.

Methods

A retrospective review of consecutive patients undergoing laser lead extractions at a single academic center. Lead extractions using only laser sheaths were analyzed. The clinical characteristics, complications, and mortality of the patients were evaluated.

Results

One hundred and twenty-one patients underwent TLEs from January 1st, 2014 to December 31st, 2018. The majority were male (N = 80, 66.1%), and the average age was 66.48 ± 14 years. The indication for removal was either laser lead malfunction or infection. A total of 30 patients (24.8%) had complications postoperatively including wound hematomas, superficial infections, and arrhythmias. The average length of stay was 9 ± 12 for all the patients in the study. 2 patients (1.6%) had injuries that required emergency surgical repair with injuries to the posterior superior vena cava and right ventricle. Both patients survived the initial injury with one patient was discharged home on day 4 and the other succumbing to his injuries on postoperative day 20.

Conclusion

Although the incidence of surgical emergencies is rare the morbidity and mortality for TLE require that surgical backup be available.

Successful avoidance of superior vena cava injury during transvenous lead extraction using a tandem femoral-superior approach

BACKGROUND

Transvenous pacemaker and defibrillator lead extraction is a higher risk procedure with variation in preferred technique. A frequently fatal complication of this procedure is perforation of the superior vena cava. We have developed a tandem femoral-superior technique that incorporates snaring of targeted leads from a femoral approach combined with use of a rotational cutting sheath advanced over the lead from the subclavian vein.

OBJECTIVE

We sought to evaluate the safety and efficacy of a tandem femoral-superior approach to lead extraction.

METHODS

Consecutive patients undergoing transvenous extraction of at least 1 pacemaker or defibrillator lead with implant duration ≥1 year in which a tandem femoral-superior technique was used as the initial extraction strategy were included. The registry spanned 2010-2018 and consisted of procedures performed by a single primary operator.

RESULTS

A total of 131 patients were included. A total of 267 leads with a mean implant duration of 9.8 years, including 90 defibrillator leads (33.7%), were targeted for extraction. No superior vena cava perforation or other vascular damage occurred. Clinical procedural success was achieved in 96.2% of cases. There were 5 major complications (3.8% of patients), with 3 being pericardial effusion requiring intervention. There were no deaths.

CONCLUSION

A tandem femoral-superior approach to lead extraction effectively eliminated superior vena cava injury. This is a safe and effective technique for transvenous lead extraction.

Triple access transvenous lead extraction: Pull-through of a lead from subclavian to jugular access to facilitate extraction

A 39-years old ventricular lead of a right-sided single-chamber pacemaker required extraction for infection. Angulation at the right subclavian-superior vena cava junction coupled with calcified fibrotic encapsulating tissue prevented advancement of a rotational dissecting sheath. To straighten the lead, it was pulled from the subclavian and out of the right internal jugular vein, whilst the Needle's-Eye Snare via the femoral access provided counter-traction. A 13-french rotational dissecting sheath was successfully advanced over the lead via the jugular access to complete the lead extraction without any complication.

The Influence of Lead-Related Venous Obstruction on the Complexity and Outcomes of Transvenous Lead Extraction

Background: Little is known about lead-related venous stenosis/occlusion (LRVSO), and the influence of LRVSO on the complexity and outcomes of transvenous lead extraction (TLE) is debated in the literature. Methods: We performed a retrospective analysis of venograms from 2909 patients who underwent TLE between 2008 and 2021 at a high-volume center. Results: Advanced LRVSO was more common in elderly men with a high Charlson comorbidity index. Procedure duration, extraction of superfluous leads, occurrence of any technical difficulty, lead-to-lead binding, fracture of the lead being extracted, need to use alternative approach and lasso catheters or metal sheaths were found to be associated with LRVSO. The presence of LRVSO had no impact on the number of major complications including TLE-related tricuspid valve damage. The achievement of complete procedural or clinical success did not depend on the presence of LRVSO. Long-term mortality, in contrast to periprocedural and short-term mortality, was significantly worse in the groups with LRSVO. Conclusions: LRVSO can be considered as an additional TLE-related risk factor. The effect of LRVSO on major complications including periprocedural mortality and on short-term mortality has not been established. However, LRVSO has been associated with poor long-term survival.

State-of-the-art narrative review: multimodality imaging in electrophysiology and cardiac device therapies

Cardiac electrophysiology procedures have evolved to provide improvement in morbidity and mortality for many patients. Cardiac resynchronization therapy (CRT), implantable cardioverter/defibrillator (ICD) placement and lead extraction procedures are proven procedures, associated with significant reductions in patient morbidity and mortality as well as improved quality of life. The applications and optimization of these therapies are an evolving field. The optimal use and outcomes of cardiac electrophysiology procedures require a multidisciplinary approach to patient selection, device selection, and procedural planning. Cardiac imaging using echocardiography plays a key role in selection of patients for CRT therapy, for guidance of left ventricular (LV) lead placement, and for optimization of atrioventricular pacing delays in patients with CRT. Cardiac computed tomography (CT) is an important tool in assessment of lead perforation, as well as assessing risk of lead extraction and procedural planning. Cardiac magnetic resonance imaging (MRI) is an important adjunct to transthoracic echocardiography for patient selection and risk stratification for defibrillator therapy for multiple disease states including ischemic cardiomyopathy, hypertrophic cardiomyopathy, cardiac sarcoidosis, and arrhythmogenic right ventricular cardiomyopathy (ARVC). Cardiac positron emission tomography (PET) is a useful adjunct to the diagnosis of device infections as well as inflammatory conditions including cardiac sarcoidosis. Our review attempts to summarize the contemporary roles of multimodality imaging in CRT therapy, ICD therapy and lead extraction therapy.

Intracardiac Echocardiography During Transvenous Lead Extraction

Transvenous lead extraction is an invaluable procedure within the contemporary management of cardiac implantable electronic devices. Transvenous lead extraction has traditionally been guided by fluoroscopy. Complementary imaging with intracardiac echocardiography can provide valuable additional information, such as identification of complications, lead-adherent echodensities, and sites of lead-tissue adherence. As such, it can be used to aid in risk stratification before lead removal, help to choose tools or techniques, and provide visual monitoring throughout the procedure. Intracardiac echocardiography can be incorporated into the lead extraction workflow of the contemporary electrophysiologist and provide valuable information supporting safety and efficacy.

Efficacy and safety of transvenous lead extraction using a liberal combined superior and femoral approach

Purpose

During transvenous lead extraction (TLE), the femoral snare has mainly been used as a bail-out procedure. The purpose of the present study is to evaluate the efficacy and safety of a TLE approach with a low threshold to use a combined superior and femoral approach.

Methods

This is a single-center observational study including all TLE procedures between 2012 till 2019.

Results

A total of 264 procedures (median age 63 (51–71) years, 67.0% male) were performed in the study period. The main indications for TLE were lead malfunction (67.0%), isolated pocket infection (17.0%) and systemic infection (11.7%). The median dwelling time of the oldest targeted lead was 6.8 (4.0–9.7) years. The techniques used to perform the procedure were the use of a femoral snare only (30%), combined rotational powered sheath and femoral snare (25%), manual traction only (20%), rotational powered sheath only (17%) and locking stylet only (8%). The complete and clinical procedural success rate was 90.2% and 97.7%, respectively, and complete lead removal rate was 94.1% of all targeted leads. The major and minor procedure-related complication rates were 1.1% and 10.2%, respectively. There was one case (0.4%) of emergent sternotomy for management of cardiac avulsion. Furthermore, there were 5 in-hospital non-procedure-related deaths (1.9%), of whom 4 were related to septic shock due to a Staphylococcus aureus endocarditis after an uncomplicated TLE with complete removal of all leads.

Conclusion

An effective and safe TLE procedure can be achieved by using the synergy between a superior and femoral approach.

Characterization of Lead Adherence Using Intravascular Ultrasound to Assess Difficulty of Transvenous Lead Extraction

Background:

Clinical factors associated with development of intravascular lead adherence (ILA) are unreliable predictors. Because vascular injury in the superior vena cava-right atrium during transvenous lead extraction is more likely to occur in segments with higher degrees of ILA, reliable and accurate assessment of ILA is warranted. We hypothesized that intravascular ultrasound (IVUS) could accurately visualize and quantify ILA and degree of ILA correlates with transvenous lead extraction difficulty.

Methods:

Serial imaging of leads occurred before transvenous lead extraction using IVUS. ILA areas were classified as high or low grade. Degree of extraction difficulty was assessed using 2 metrics and correlated with ILA grade. Lead extraction difficulty was calculated for each patient and compared with IVUS findings.

Results:

One hundred fifty-eight vascular segments in 60 patients were analyzed: 141 (89%) low grade versus 17 (11%) high grade. Median extraction time (low=0 versus high grade=97 seconds, P <0.001) and median laser pulsations delivered (low=0 versus high grade=5852, P <0.001) were significantly higher in high-grade segments. Most patients with low lead extraction difficulty score had low ILA grades. Eighty-six percentage of patients with high lead extraction difficulty score had low IVUS grade, and the degree of transvenous lead extraction difficulty was similar to patients with low IVUS grades and lead extraction difficulty scores.

Conclusions:

IVUS is a feasible imaging modality that may be useful in characterizing ILA in the superior vena cava-right atrium region. An ILA grading system using imaging correlates with extraction difficulty. Most patients with clinical factors associated with higher extraction difficulty may exhibit lower ILA and extraction difficulty based on IVUS imaging.

Graphic Abstract:

A graphic abstract is available for this article.

Predictors of the need for supportive femoral approach during transvenous extraction of pacemaker and defibrillator leads in Japanese patients

BACKGROUND

Studies on femoral approach during transvenous lead extraction (TLE) are limited.

METHODS

We retrospectively evaluated 75 patients undergoing TLE from September 2014 through November 2019 via supportive femoral approach (Femoral/Superior group; n = 22) and superior approach alone (Superior group; n = 53).

RESULTS

No significant between-group differences were observed regarding patients' baseline characteristics except for a higher incidence of access vein occlusion in the Femoral/Superior group (59.1% vs. 31.4%; P = .037). The Femoral/Superior group exhibited significantly longer dwell times of the oldest extracted lead (median: 13.4 years; interquartile range [IQR]: 8.8-21.2 years vs. median, 7.2 years; IQR: 3.7-10.8 years; P < .001) and a higher incidence of passive fixation ventricular pacemaker lead (81.8% vs. 39.6%; P = .001). Multivariate logistic analysis showed that access vein occlusion (odds ratio [OR]: 4.07, 95% confidence interval [CI]: 1.08-15.3; P < .001) and dwell time of the oldest extracted lead (per year) (OR: 1.22, 95% CI: 1.09-1.37; P = .038) were predictors of the need for supportive femoral approach. Receiver operating characteristic curve analysis revealed that 11.8 years from implant was the cutoff for the need for supportive femoral approach (sensitivity 68.2%, specificity of 81.1%, area under the curve 0.81).

CONCLUSIONS

Access vein occlusion and long dwell time of the oldest extracted lead predict a high probability of the need for supportive femoral approach. Supportive femoral approach may be necessary in patients with leads that are implanted for >11.8 years and whose access veins are occluded.

Wire countertraction for sheath placement through stenotic and tortuous veins: The “body flossing” technique

Background

Innominate vein stenosis and venous tortuosity are common findings during cardiac implantable electronic device upgrades or replacements and present a challenge to the implanting physician. Various techniques have been described to facilitate lead placement, including serial dilation, balloon venoplasty, and percutaneous access medial to the stenosis, each with its own benefits and risks.

Objective

The purpose of this study was to assess the feasibility, safety, and efficacy of the wire countertraction (“body flossing”) technique to facilitate sheath placement through tortuous and stenotic vessels.

Methods

Patients undergoing cardiac implantable electronic device procedures requiring the body flossing technique due to inability to place vascular sheaths over the wire through stenoses or tortuosity were retrospectively analyzed. Clinical characteristics, procedural equipment, and outcomes were analyzed.

Results

Simultaneous countertraction was successful in all attempted cases, including 8 patients with stenoses and 2 with tortuosity. In 2 of the stenosis cases, venoplasty had previously failed. No complications occurred.

Conclusion

Simultaneous countertraction (body flossing) is an effective tool to overcome venous stenosis and tortuosity that are amenable to wire advancement but not to vascular sheaths. It seems to be a safe and effective alternative to other techniques used in these scenarios.

Algorithm for the analysis of pre-extraction computed tomographic images to evaluate implanted lead-lead interactions and lead-vascular attachments

BACKGROUND

The number of lead extractions is growing because of the greater population and increasing age of individuals with a cardiac implantable electronic device. Lead extraction procedures can be complex undertakings with risk of significant mortality, and vascular tears in the superior vena cava are of greatest concern.

OBJECTIVE

The purpose of this study was to study whether a novel algorithm that analyzes pre-extraction computed tomographic (CT) images can determine the likelihood and location of lead-lead interactions and lead-vessel attachment within patients' venous vasculatures. This information can be used to identify potential case challenges in the planning stages.

METHODS

We developed an algorithm to estimate the presence and position of lead-lead interactions and lead-vessel adherences by tracking distance between the leads and distance between the lead and superior vena cava in a sample of 12 patients referred to the United Heart and Vascular Clinic for lead extractions due to infection (n = 5), lead failure (n = 5), and tricuspid regurgitation (n = 2).

RESULTS

Preliminary results indicate that the developed algorithm successfully identified lead-lead and lead-vascular attachments compared to review of CT images by medical experts.

CONCLUSION

With future validation and clinical implementation, this algorithm could aid physician preparedness by minimizing intraprocedural emergencies and may improve patient outcomes.

Femoral extraction of transvenous leads and leadless pacemakers-A review of the data, tools, and procedural steps

Extraction of transvenous leads via the femoral route might be needed when extraction via the implant vein fails or when retained lead fragments exist. The skill set required for this procedure is unique as it relies on the ability to snare and the use of a variety of shelf tools. In this era of leadless pacing, this skill set might be called upon more frequently. In this article, we review the data, tools, and procedural steps of femoral lead extraction and retrieval/extraction of leadless pacemakers.