Transvenous lead extraction of fractured or infected cardiac implantable electronic devices (CIEDs) remains a necessary skill set for cardiac electrophysiologists in both academic and private practices. Avoiding catastrophic vascular tears or cardiac perforation requires meticulous attention to lead preparation, skillful mechanical or laser sheath manipulation, frequent outer sheath support, vascular balloon occlusion preparation, and real-time echocardiographic monitoring of the heart. Snaring leads from a femoral approach and removing them from the groin provides an alternative strategy to performing the same from the chest. Recently, Schaller et al1 described a technique of simultaneous traction on a targeted lead after snaring from the femoral approach. In this report, we describe our approach to a high-risk lead extraction case involving a fractured implantable cardioverter-defibrillator (ICD) lead implanted 13 years prior, which included an integration of all the above-described techniques through a two-operator system to ensure efficacy, efficiency, and safety.
A 75-year-old man with a single-chamber ICD implanted in 2005 was noted to have electromagnetic noise on routine interrogation of his device in May 2018. He had a history of hypertension, diabetes mellitus, hyperlipidemia, and sudden cardiac arrest for which he received a single-coil, single-chamber ICD system with a Riata 1582 (St. Jude Medical) lead (Figure 1).
His lead had undergone a recall due to a known propensity for the conductor cable to erode through the insulation of the lead. Given its high-risk features of being older than 5 years as well as a lead with a known higher risk of malfunction, the patient was scheduled for an ICD system removal with lead extraction using two EP operators, as per our standard approach.
The patient was brought to our hybrid operating room (OR) with two electrophysiologists, a cardiothoracic (CT) surgeon, cardiac anesthesiologist, and perfusion team on standby during the entire case in the OR. One electrophysiologist would be the primary operator working from the device pocket, with the second focusing on the femoral tools. We have 4 units of packed red blood cells typed and crossed for the patient and present in the room for every extraction case. After general anesthesia induction and intubation, a standard chlorhexidine scrub was performed followed by a standard CT surgical drape. We also had a transesophageal echocardiography (TEE) probe placed for preoperative imaging as well as intraoperative imaging for the entirety of the case by an echocardiography sonographer.
Both electrophysiologists then commenced simultaneously on their preparatory tasks. The first operator opened the device pocket, detached and removed the generator, freed the lead from its chronic pocket adhesions and suture sleeve, and prepared the lead in standard fashion by cutting off the lead header, inserting a locking stylet, and securing the defibrillation coils and outer insulation with sutures tied to the locking stylet. He then prepared the laser and rotational extraction sheaths, since we frequently switch between modalities depending on the type of vascular adhesions encountered along the way.
The second operator concomitantly obtained two right femoral venous access points (although not necessary in this patient, a third access site is often obtained for pacemaker-dependent patients who need temporary pacing) and a femoral artery access point under ultrasound guidance for invasive blood pressure monitoring line and, if needed, for a peripheral bypass circuit. Through one of the venous access points, a Bridge Occlusion Balloon (Spectranetics, now part of Philips Healthcare) was inserted over a wire that had been inserted up to the right subclavian (SC) vein, to a length where the radio-opaque marker stopped just below the level of the right clavicle. The balloon was then inflated with a mixture of saline and contrast during fluoroscopic imaging to ensure appropriate occlusion of the innominate-superior vena cava (SVC) junction down to the SVC-right atrial (RA) junction without “watermelon-seeding” of the balloon back into the RA (Figure 2). The shaft of the balloon was marked with a white sticker at the level of its entry into the venous sheath to denote the appropriate length needed to insert at the level we just tested, and then the balloon was deflated and retracted to the level of the liver while keeping the wire in place in the right SC vein.
Through the second venous access point, a 13 mm Needle’s Eye Snare (Cook Medical) was inserted through a 16 French curved outer workstation and manipulated under fluoroscopy to snare the ICD lead shaft at the RA level (Figure 3). At this point, the first operator had just finished preparing and loading the extraction sheath and was ready to start advancing it into the vasculature. The second operator then moved to the left side of the patient after changing gloves and assisted with holding downward traction on the lead by pulling on the snare, helping with the back end of the lead, and exchanging ideas and opinions with the first operator to decide on which tools to use as next steps if difficult adhesions were met (Figure 4). Holding simultaneous countertraction from the chest and downward traction from the femoral snare on the lead provided a favorable sturdy rail to allow the extraction sheaths to follow down the lead with counterpressure force and without undo lateral forces along the innominate-SVC junction or the SVC-RA junction. This resulted in the safe removal of the 13-year-old ICD lead, and eventual replacement with a new system (Figure 5).
This case report serves to illustrate the protocol we have developed for extraction of higher risk leads, which we defined in this case as an ICD lead implanted for over 5 years.2 Additional risk factors we take into account include the presence of an SVC coil, the presence of chronic kidney disease especially if on hemodialysis, elderly or frail patients, or if the lead is known to have poor extraction properties such as easy friability of the lead. Being able to operate with another experienced extractor during the case allows for an efficient workflow to prepare and deploy a femoral snaring system, as well as a resource for discussing important points during the case where the best options are weighed and executed. The preparation of a balloon occlusion device ahead of time has been recommended by expert consensus during high-risk cases,3 and has already been proven to safely deliver patients to an open-chest rescue if a tear in that area occurs.4 Also, we especially feel that simultaneous traction from above through the locking stylet and below through femoral snaring of the lead adds incremental safety to the procedure, since it reduces lateral forces when the extraction sheaths come around the “danger zone” of the innominate-SVC junction leading into the SVC-RA junction.
Lead extraction of chronic indwelling CIED leads poses a challenging and dangerous situation that risks tearing of the innominate vein, SVC, or cardiac structures. Coordinated efforts between two experienced extractors and an armamentarium of helpful tools makes these risky procedures more effective, efficient, and most importantly, safer.
Disclosures: The authors have no conflicts of interest to report regarding the content herein.
Acknowledgements: We would like to thank Dr. Tomomi Oka (CT surgery), the OR and cath lab staff at Mills Peninsula Medical Center, Elizabeth Powers from Spectranetics, and David Alexander from Cook Medical. Without all of their support, our lead extraction program would not be possible.
- Schaller RD, Sadek MM, Cooper JM. Simultaneous lead traction from above and below: a novel technique to reduce the risk of superior vena cava injury during transvenous lead extraction. Heart Rhythm. 2018;15(11):1655-1663.
- Afzal MR, Daoud EG, Matre N, et al. RIsk Stratification prior to lead Extraction and impact on major intraprocedural complications (RISE protocol). J Cardiovasc Electrophysiol. 2019 Sep 9.
- Wilkoff BL, Kennergren C, Love CJ, Kutalek SP, Epstein LM, Carrillo R. Bridge to surgery: best practice protocol derived from early clinical experience with the Bridge Occlusion Balloon. Federated agreement from the Eleventh Annual Lead Management Symposium. Heart Rhythm. 2017;14(10):1574-1578.
- Azarrafiy R, Tsang DC, Wilkoff BL, Carrillo RG. Endovascular occlusion balloon for treatment of superior vena cava tears during transvenous lead extraction. Circ Arrhythm Electrophysiol. 2019;12(8):e007266.