As the number and complexity of cardiac implantable devices continues to rise, the need to be well versed in all aspects of lead management will become increasingly important.1 Over the past 25 years or so, improvements in the techniques and tools utilized in transvenous lead extraction (TLE) have resulted in a safe and effective procedure.2,3 While the majority of contemporary cases are performed using a superior approach from the device pocket and a powered sheath (laser, electrosurgical, or rotational), the inferior approach utilizing snares via a femoral venous access is an important part of any extractor’s armamentarium.3
A 48-year-old male with a history of nonischemic cardiomyopathy, left bundle branch block, biventricular ICD, type II diabetes mellitus, atrial fibrillation, and obstructive sleep apnea was referred to our institution with erythema and drainage from his device pocket. His original system was implanted in 2011, and two months prior to his referral, he underwent a pulse generator change at an outside hospital. In light of his clinical pocket infection, the decision was made to proceed with total system extraction, and he was brought to the electrophysiology lab. Bilateral femoral access was obtained under ultrasound guidance with 4 French (Fr) arterial and 6 Fr venous sheaths inserted on the right, along with 12 Fr and 6 Fr sheaths on the left. This setup allows for continuous blood pressure monitoring (right-sided 4 Fr arterial sheath), pacing via a deflectable RV catheter (right-sided 6 Fr venous sheath), use of a compliant rescue balloon (left-sided 12 Fr venous sheath), and access for potential use of femoral snares (left-sided 6 Fr venous sheath). An Amplatz Super Stiff™ Guidewire (Boston Scientific) was then inserted though the 12 Fr sheath and positioned in the right subclavian vein, and a Bridge Occlusion Balloon™ (Spectranetics/Philips IGTD) was staged in the inferior vena cava (IVC). Next, the device pocket was opened, with frank pus noted around the device. The leads were then freed from the underlying tissue with electrocautery, despite some difficulty related to calcification within the pocket. Standard stylets were inserted into the RA and RV leads, and attempts were made to withdraw the active fixation screw, both of which were unsuccessful. At this point, the standard stylets were removed and all three leads were cut. Locking stylets (Spectranetics/Philips IGTD) were then advanced to the lead tips and deployed. The insulation and high-voltage conductors were then fixed to the leads with silk suture. A 14 Fr laser sheath (Spectranetics/Philips IGTD) was then prepped and advanced over the right atrial lead to just under the clavicle, where progress was halted due to calcification. Attempts at advancing the laser sheath over the other leads resulted in similar difficulty in traversing the vasculature beneath the clavicle, despite significant traction and manual disruption with the outer sheath. When working on the right ventricular ICD lead, the proximal portion broke and withdrew back into the vasculature. At this point, the decision was made to attempt to snare the leads from below.
Overview of Femoral Techniques
Despite somewhat longer procedure and fluoroscopy times,4 there are a variety of clinical scenarios that warrant consideration of a femoral approach to lead extraction, including cut or abandoned leads, failure of the superior approach, and distal lead support to maintain vascular access.5 The foundation of the inferior approach is a large, typically 16 Fr, long sheath (Byrd Femoral Workstation™, Cook Medical) that extends from the groin to the heart with the ability to be advanced over the captured lead, either superiorly toward the superior vena cava (SVC) or down into the right ventricle (RV). This allows for both passage of the various tools, countertraction once the lead is captured, and a conduit to remove the lead from the body. Through this sheath, a variety of tools can be inserted to capture the lead one intends to remove. Broadly, these can be broken down into three main categories: 1) multicomponent snares, 2) multiloop snares, and 3) single loop snares. The overall concept with snaring involves forming a closed loop around the object being removed, advancing a sheath over that loop to cinch it down onto the object, and applying traction to the system. This can be achieved in a variety of ways, and which snare to choose depends on a number of factors, including operator skill set, familiarity, lead integrity, and approach.
With leads or lead fragments that are fixed at both ends, a common initial approach is to use a multicomponent snare such as the Needle’s Eye™ Snare (Cook Medical). The closed loop is created by catching the lead with the hook-shaped portion of the snare and then depressing a plunger in the handle, which advances a second component through the hook that closes the loop. A telescoping sheath is then advanced over the system to tighten the loop down on to the lead. If a multicomponent snare is unavailable, or unable to be manipulated into the appropriate position to grasp the lead, a similar approach can be taken using separate individual tools. First, a wire is manipulated up and over the lead, often with the assistance of a pigtail catheter, and then the free end of the wire is captured with a single loop or multiloop snare to close the circle. Alternatively, a deflectable pacing or ablation catheter can replace the wire, or a deflectable sheath can replace the pigtail.
Leads or lead fragments with a free end can be more difficult to capture with the multicomponent approach. In these scenarios, single or multiloop snares can be of use. A deflectable sheath can be used to manipulate the snare into close proximity of the free end of the lead. The free end of the lead is then captured with one or more of the loops, and the telescoping sheath cinches down on to it, allowing for traction to be applied.
The femoral approach can also be used as an adjunct to the superior techniques. A common scenario is a patient presenting for an upgrade of their previously implanted system that is complicated by vascular occlusion. In this case, TLE can be a useful way to recannulate the vessel while simultaneously reducing lead burden. However, the lead being removed may release at times as traction is applied before the laser or mechanical sheath is advanced beyond the occlusion. In this case, femoral techniques can be used to secure the distal portion of the lead, providing enough support to safely traverse the occluded portion of the vein. At that point, the snare can be released and the lead pulled through the sheath. Additionally, snaring can be used to redirect superior traction forces in an effort to pull the lead off of the vessel wall or reduce tension on the RV portion of a lead when traction results in excessive drops in blood pressure.
Case Presentation, Continued
The left-sided 6 Fr femoral venous sheath was exchanged for a Byrd Femoral Workstation and a Needle’s Eye Snare advanced into the right atrium. Initially, both the left ventricular (LV) and right atrial (RA) leads were captured, and as traction was applied, the RA lead tip was dislodged (Figure 1A). The snare was then released and the RA lead tip migrated superiorly (Figure 1B). With additional manipulation, the LV lead body was snared again, allowing for enough support to advance the laser sheath down to the point where the lead was able to be removed (Figure 1C and 1D). With the LV lead out, the RA lead came out with countertraction applied by the laser sheath. The RV lead proved to be more difficult. With no proximal portion of the lead accessible from the pocket, the only option was to use femoral techniques. Despite multiple attempts, capture with the hook portion of the Needle’s Eye Snare was unsuccessful, so it was removed. An Agilis™ NxT steerable introducer (Abbott) was then inserted and positioned around the lead (Figure 2A). Next, a Wholey™ guidewire (Medtronic) was inserted through the sheath, around the mid-portion of the lead, and down into the IVC (Figure 2B). The Agilis was then removed, and a single-loop snare was used to capture the distal portion of the wire (Figure 2C and 2D). As the femoral sheath was advanced and traction applied (Figure 2E and 2F), the mid-portion of the lead broke away and was removed, leaving the two coils in place. The Agilis was again inserted and positioned near the distal aspect of the SVC coil. A multiloop EN Snare™ Endovascular System (Merit Medical) was then used to grab the SVC coil (Figure 3A and 3B). Traction applied to the coil resulted in it unravelling as it came out (Figure 3C). Lastly, the Agilis and EN Snare system was again used to remove the RV coil (Figure 3D and 3E) by securing the free end near the tricuspid valve annulus. The final result was complete system removal via a hybrid superior and inferior approach (Figure 4).
While the superior approach to TLE remains the mainstay of contemporary practice, femoral lead extraction techniques can serve as an important adjunct or bailout in difficult cases. They remain a vital skill for the extracting physician to master and an important component of any comprehensive lead management program.
Disclosure: Dr. Cunnane has no conflicts of interest to report regarding the content herein.
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