The need for transvenous lead extraction (TLE) is increasing. As patients are living longer with their devices, extractors are facing increasingly difficult procedures that include older and multiple leads. A successful extraction program requires access to and experience with all tools that may be required. In this report, we review the use of a novel, shielded mechanical extraction sheath to successfully remove older, chronic pacemaker and ICD leads (22 and 17 years).
The patient was a 66-year-old male with a history of ischemic cardiomyopathy and a cardiac arrest in 1999. His initial ICD was implanted August 17, 1999 (SPL SPO2 lead, St. Jude Medical [now Abbott]; Figure 1). He underwent generator changes in May 2006 and July 2016. At the time of his last generator change, the pace-sense impedance was 718 ohms. In follow-up, it had fallen to 200 ohms. In addition, his last echocardiogram in September 2016 demonstrated a fall in ejection fraction (EF) to 35%, coupled with class II heart failure symptoms. His ECG demonstrated chronic atrial fibrillation with a LBBB pattern and QRS duration of 152 msec. Therefore, he was referred for extraction and “upgrade” to a biventricular (BiV) ICD.
The procedure was performed under general anesthesia in a hybrid operating room. Given the age of the ICD lead, the calcification in the pocket, and the young age of the patient at implantation (49 years old), the decision was made to use the TightRail (Spectranetics) rotating mechanical dilator sheath as the primary tool. After the lead was freed in the pocket and the anchor was removed, three locking stylets (LLD EZ, Spectranetics) were placed distally in each of the coils (the SPO2 has coils running to the distal electrode as well as to each of the shocking electrodes). A #5 silk was tied to the outside of the lead. A 13 French TightRail was employed to free the lead from encapsulating scar tissue at the venous entry site, along the vasculature and in the heart. The TightRail made slow progress through the calcified binding sites, and the lead was successfully removed with countertraction. Access was maintained through the extraction sheath by placing a guidewire after the lead was removed (Figure 2). A new CRT-D system was then implanted, with placement of a new ICD lead and quadripolar LV lead in a high posterolateral branch. (Figure 3)
The patient was a 74-year-old male with both recurrent atrial arrhythmias and heart block. He underwent initial pacemaker placement in 1992 for heart block (atrial lead 4524, ventricular lead 4042) (Figure 4). He has had recurrent episodes of atrial fibrillation and typical and atypical atrial flutter. An initial atrial flutter ablation was performed in March 2010, and subsequent ablations for atrial fibrillation and atypical atrial flutter were performed in 2011 and 2012. The second left atrial ablation procedure was complicated by a perforation requiring cardiac surgery to repair. In August 2013, the patient underwent repeat ablation of the posterior wall and isolation of the left atrial appendage. His last ablation took place on November 10, 2016. On follow-up, the RV lead had an insulation issue and was programmed in the unipolar mode. On a TEE prior to his last ablation, his ejection fraction had fallen to 25-30%. It was thought that his EF had fallen due to chronic RV pacing. He was referred for extraction with an upgrade to a BiV pacemaker. However, an extensive family history demonstrated multiple family members with cardiomyopathy. The patient’s early heart block, extensive atrial arrhythmias, and now falling LV function (along with NSVT) more likely represented a familial cardiomyopathy. Therefore, he underwent extraction with an “upgrade” to a BiV ICD. As in the previous case, due to the calcific scarring, the decision was made to proceed with a TightRail extraction sheath. A temporary pacing wire was placed via the left femoral vein. The leads were freed and anchors removed. The leads were cut and locking stylets placed distally. A #5 silk was tied to the outside of each lead. There was extensive calcific binding at the venous entry site and along the course of the leads. The TightRail made slow and steady progress, resulting in successful removal of first the atrial and then the ventricular lead (Figure 5). A new BiV ICD system was then placed (Figure 6).
In this article, we report the use of a novel mechanical extraction sheath to safely and effectively perform TLE in 2 patients with old, calcified leads. While multiple tools may be required during any given procedure, most extractors have their preferred tools. Historically, I have had excellent success with the laser sheath when a “powered” extraction sheath was required. To safely employ the laser sheath, steady traction must be maintained on the lead. The lead absolutely must act as a “rail” for the sheath. In some cases, especially when entering the SVC, significant traction must be applied to navigate the curvature. In addition, while very effective, the laser does not “vaporize” calcified scar tissue. The TightRail (Figure 7) was developed as a mechanical alternative to the laser sheath. The shaft of the sheath is very flexible, and therefore, the lead requires less traction for the sheath to track the lead. The mechanical rotating blades are capable of cutting through calcific scar tissue.
My initial experience with the TightRail was not good, to say the least. I found the shaft to be so “floppy” that it was difficult to engage the distal end with the binding sites. After 4 cases, I affectionately referred to the TightRail as “junk” and went back to the laser sheath. After a few months, I decided to give the TightRail another chance. I initially employed it on calcific cases when the laser was not making progress. I asked others who used the sheath what tips they had to ensure success. Using the sheath, I learned that the distal end must engage the binding sites. This can be done by applying pressure on the shaft as close to the venous entry site as possible. Constant pressure can then be applied. Less traction is required, but so is much more patience. The sheath makes progress much slower than the laser. Lastly, occasionally disengaging the distal end, withdrawing, and then re-engaging can help make progress. My experience during these cases has led me to choose the TightRail as my first option for older leads. Of the TLE procedures I have performed over the past 3 months, 21 cases were in patients with “older” leads, an average lead age of 20.4 (14-33) years. The requirement of less traction is also an advantage for leads with a higher risk of disrupting during extraction. In addition to effectively managing older and calcific leads, the TightRail is also a safe mechanical tool that allows for extraction programs in parts of the world where access to the laser is limited or non-existent. The shielded blade, which rotates in both directions with each activation, along with the non-rotating outer shaft, prevents “winding” of non-targeted leads.
Each extraction procedure must be approached individually with all tools available. Despite my initial negative experience and my holding onto “the way I do it,” my willingness to give the TightRail another try has added an important tool to my toolbox. This demonstrates, at least sometimes, that you can teach an old dog new tricks!
Disclosure: The author has no conflicts of interest to report regarding the content herein. Outside the submitted work, Dr. Epstein reports receiving personal fees (lectures/consultant) for Medtronic, St. Jude Medical (now Abbott), Boston Scientific, and Spectranetics.