Exposed subcutaneous implantable devices: an operative protocol for management and salvage

Double Layer Reconstruction of Exposed Cardiac Implantable Electronic Devices in Elderly Patients

Background Elderly patients with multiple comorbidities may not be candidates for cardiac implanted electronic device (CIED) explantation in cases of exposition. Excision of all unhealthy and inflamed scar tissue results in a skin defect that must be covered. Small- to moderate-sized local skin flaps and subpectoral placement of CIEDs have been described in the literature. However, these techniques still could not eliminate the risk of recurrence. In terms of minimizing the recurrence risk, we aim to increase the flap dimensions for getting better circulation and tension-free closure after subpectoral placement. Material and methods Six patients who were operated for a dual-layer reconstruction of exposed cardiac implants between 2017 and 2020 were included in the study. All patients were referred to plastic surgery as soon as the wound biopsy culture results were negative after systemic and topical antibiotic treatment by cardiology department. Results No flap loss or wound dehiscence was seen with a mean duration of 11 months follow-up. Early hematoma was encountered in a patient who was managed with irrigation and drain renewal. One patient developed suture abscess in the second month postoperatively. Knots were removed and wound healed without further intervention. Conclusion Double layer closure of exposed cardiac implants with large breast fasciocutaneous flap after subpectoral placement of pulse generator and leads suggest durable and reliable coverage in elderly patients with multiple comorbidities.

Vascularized Muscle Flap to Reduce Wound Breakdown During Flexible Electrode-Mediated Functional Electrical Stimulation After Peripheral Nerve Injury

The success of devices delivering functional electrical stimulation (FES) has been hindered by complications related to implants including skin breakdown and subsequent wound dehiscence. Our hypothesis was that a vascularized muscle flap along the dorsal surface of an epimysial electrode would prevent skin breakdown during FES therapy to treat atrophy of the gastrocnemius muscle during peripheral nerve injury. Resection of a tibial nerve segment with subsequent electrode implantation on the dorsal surfaces of the gastrocnemius muscle was performed on ten Lewis rats. In five rats, the biceps femoris (BF) muscle was dissected and placed along the dorsal surface of the electrode (Flap group). The other five animals did not undergo flap placement (No Flap group). All animals were treated with daily FES therapy for 2 weeks and degree of immune response and skin breakdown were evaluated. The postoperative course of one animal in the No Flap group was complicated by complete wound dehiscence requiring euthanasia of the animal on postoperative day 4. The remaining 4 No Flap animals showed evidence of ulceration at the implant by postoperative day 7. The 5 animals in the Flap group did not have ulcerative lesions. Excised tissue at postoperative day 14 examined by histology and in vivo Imaging System (IVIS) showed decreased implant-induced inflammation in the Flap group. Expression of specific markers for local foreign body response were also decreased in the Flap group.

Complications arising from transfemoral, percutaneous implantation of an indwelling port-catheter system for hepatic infusion chemotherapy: Case series of the management and salvage of the system

INTRODUCTION

Regional hepatic arterial infusion of chemotherapy is performed for unresectable liver tumors via percutaneously implanted port-catheter systems; while these port-catheter systems are effective administration routes, they are associated with various complications. Withdrawal of the system is considered if the complications occur, but repeated hepatic arterial infusion of chemotherapy (HAIC) via an implanted port-catheter system is a last-resort treatment for unresectable advanced liver cancer, and the treatment must be continued. We discuss various cases with complications arising in the indwelling port area in hepatic arterial infusion of chemotherapy and report whether the system was salvaged.

METHODS

Between August 2013 and October 2017, eight patients (six males and two females) aged 61-80 years (mean age 76.6 years) with complications arising in a transfemoral indwelling port site for HAIC were referred to our department. All patients requested preservation of the system, especially the catheter. Each patient was assessed for the presence of "gross infection" based on a comprehensive evaluation of clinical findings and blood test results. In cases of "no gross infection," we performed catheter salvage procedures. If there was no clinical improvement following the catheter salvage procedure, the port-catheter system was withdrawn. This research work has been reported in line with the PROCESS criteria.

RESULTS

The port-catheter systems were withdrawn in two patients: one due to lasting infection and the other due to ulcer recurrence. Three cases were treated by removal of hematoma through an incision and ointment. The system was withdrawn in one of these cases due to exacerbation of ulcer; thus, the catheters were salvaged in five patients. None of these five patients experienced a relapse from 3 months to over 1 year after the procedure.

CONCLUSION

The success of subcutaneous HAIC significantly impacts a patient's prognosis, especially for unresectable tumors and residual tumor recurrences. Initially, we chose to preserve the devices without removal, particularly if there was no infection. However, this approach led to a delay in chemotherapy, prolongation of healing time, and additional complications. These cases demonstrate the importance of a thorough consultation with the patient's oncologist to discuss whether or not the device should be conserved.

Novel technique to manage pacemaker exposure with buried flap reconstruction: case series

Objective

Exposure of implantable electrical devices may increase morbidity and mortality significantly. Usually superficial infections are conservatively managed whereas invasive infections necessitate complete capsulectomy, sub-pectoral placement or implant exchange. Most commonly inadequate soft tissue coverage, soft tissue thinning and scar dehiscence over the edge of the pacemaker are the primary predisposing event. Multiple local surgical options have been described, however, with all these designs, the final scar still remains over the edge of the pacemaker and continue to have a tendency of thinning out with time. We have described a local skin flap which can be de-epithelialized and partially buried under the skin to increase the thickness over the pacemaker edge, thereby preventing further recurrence.

Methods

Three patients admitted in the Cardiology Department presented with impending exposure (n=2)and exposed implant (n=1) over the edge of pacemaker with superficial infection. Local modified rotation skin flap which was de-epithelialized and partially buried under the skin to increase the thickness over the pacemaker edge was performed under local anaesthesia in all the cases.

Results

Flaps settled well in all patients with no evidence of infection, scar dehiscence and recurrence over a follow-up period of 2 years.

Conclusions

This flap technique is recommended for cases of impending pacemaker exposure resulting due to scar dehiscence over the edge and helps by addressing the predisposing factors at an initial stage. In our experience, this technique also helped to salvage exposed pacemaker with superficial infection. To our bestof knowledge this technique has not been described before in the literature.

Soft Tissue and Skin Reinforcement with Acellular Dermal Matrix to Protect Implanted Cardioverters/Defibrillators and Pacemakers

Cardiac pacemakers and implantable cardioverters/defibrillators are often placed in older patients with thin skin and scanty subcutaneous tissue. These devices and cardiac leads are at risk for progressive skin erosion and exposure leading to infection. To prevent this severe complication, we developed a reinforcing insertion of acellular dermal matrix. Twenty-two of 24 patients had successful implantation with long-term avoidance of skin erosion

Is capsulectomy a feasible and useful measure in internal pulse generator replacement procedures? A technical note on the use of the PEAK PlasmaBlade(TM)

BACKGROUND

Implantable pulse generator (IPG) replacement is considered a simple procedure, but in case of extension cable damage or IPG pocket infection, it can dramatically affect a patient's quality of life. Higher risk of infection has been reported after IPG replacement procedures rather than after primary deep brain stimulation lead implantation, and some authors suggested that the IPG pocket capsule could play a pivotal role in causing it. In this technical note we present a capsulectomy technique adopted in IPG replacement procedures.

METHODS

Between July and October 2015, we carried out ten outpatient IPG replacement procedures at the chest and abdomen under local anesthesia for battery depletion using the PEAK PlasmaBlade(TM). All patients were followed for at least 2 months to rule out any hardware malfunction and infection.

RESULTS

All ten procedures were uneventful. No extension cable damage occurred. No IPG pocket infection occurred, also not in the follow-up. Mean surgical time was 30 min.

CONCLUSIONS

Complete capsulectomy is not feasible with basic surgical instruments, and the PEAK PlasmaBlade(TM) pencil appears to be a helpful tool in carrying out the procedure.