Scholarly article on topic 'Percutaneous lead extraction by femoral approach, case report'

Percutaneous lead extraction by femoral approach, case report Academic research paper on "Clinical medicine"

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Abstract of research paper on Clinical medicine, author of scientific article — Uğur Kocabaş, Hamza Duygu, Nihan Kahya Eren, Zehra İlke Akyıldız, Cem Nazlı

Abstract Background Transvenous lead extraction is usually done via subclavian route, here we present an extraction case performed by femoral approach. Case report 72year old patient who has a VVI pacemaker with one passive fixation and one active fixation lead admitted to our clinic with pacemaker decubitus. We decided to remove all hardwares and insert a new battery and lead on contralateral side. However the first passive lead was deep inside the subclavian region so we planned to use femoral approach for lead extraction if subclavian approach fails in the patient. In the catheterization laboratory active fixation lead is easily explanted by simple traction but the passive lead could not be reached by subclavian approach. We decided to use the femoral Byrd Workstation 12F™ and Needle's eye Snare® to extract lead femorally. The lead is snared at subclavian end and is extracted by applying gentle simple traction and taken into the femoral Byrd Workstation 12F™. We implanted new pacemaker at contralateral side and discharged patient uneventfully. Conclusion Percutaneous femoral approach for lead extraction is generally used as bail-out procedure for leads that cannot be extracted by subclavian approach but as in our case it can be used primarily according to the clinical presentation of the patient.

Academic research paper on topic "Percutaneous lead extraction by femoral approach, case report"

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International Journal of the Cardiovascular Academy

journal homepage: www.elsevier.com/locate/ijcac

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Percutaneous lead extraction by femoral approach, case report

Ugur Kocabaç a,*< Hamza Duygu b, Nihan Kahya Eren a, Zehra like Akyildiz a, Cem Nazli '

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a izmir Atatürk Training and Research Hospital Cardiology Department, izmir, Turkey b Neareast University Faculty of Medicine Cardiology Department, Nicosia, Cyprus

ARTICLE INFO

Article history:

Received 12 May 2015

Received in revised form 26 July 2015

Accepted 27 July 2015

Available online 4 September 2015

Keywords: Pacemaker Lead

Extraction words

ABSTRACT

Background: Transvenous lead extraction is usually done via subclavian route, here we present an extraction case performed by femoral approach.

Case report: 72 year old patient who has a VVI pacemaker with one passive fixation and one active fixation lead admitted to our clinic with pacemaker decubitus. We decided to remove all hardwares and insert a new battery and lead on contralateral side. However the first passive lead was deep inside the subclavian region so we planned to use femoral approach for lead extraction if subclavian approach fails in the patient. In the catheterization laboratory active fixation lead is easily explanted by simple traction but the passive lead could not be reached by subclavian approach. We decided to use the femoral Byrd Workstation 12 F™ and Needle's eye Snare® to extract lead femorally. The lead is snared at subclavian end and is extracted by applying gentle simple traction and taken into the femoral Byrd Workstation 12 F™. We implanted new pacemaker at contralateral side and discharged patient uneventfully.

Conclusion: Percutaneous femoral approach for lead extraction is generally used as bail-out procedure for leads that cannot be extracted by subclavian approach but as in our case it can be used primarily according to the clinical presentation of the patient.

© 2015 The Society of Cardiovascular Academy. Production and hosting by Elsevier B.V. All rights reserved. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Introduction

Due to the advancements in cardiac device technology there has been an increase in pacemaker and internal cardioverter defibrillator implantation numbers and as a result we can see more patients with device related problems which require complete removal of pacemaker and leads.1 Removal of pacemaker generator is usually a straightforward procedure however same is not true for the leads which are fixed to heart and great vessels by fibrous reaction.

In literature special methods including mechanic extraction systems, laser devices and radiofrequency devices are used for lead extraction and in case these methods fail surgical operation may be required. Mechanic dilator sheath lead extraction system which is developed recently has been used for lead extraction in our country.2 Most extraction systems use subclavian route for transvenous extraction however to be successful in this method the lead must have enough length of undamaged loop remaining at the subclavian venous entry site. In this

☆ There is no financial support source and conflict of interest of authors for writing of this manuscript.

* Corresponding author. Tel.: +90 232 2444444 2526, +90 532 791 94 73 (GSM). E-mail addresses: ugurk46@yahoo.com (U. Kocaba$), hamzakard@yahoo.com (H. Duygu), nkahya77@yahoo.com (N.K. Eren), zehrailkesavas@yahoo.com (Z.l. Akyildiz), cemekomed@yahoo.com (C. Nazli).

Peer review under responsibility of The Society of Cardiovascular Academy.

manuscript we will present a lead extraction case which is not suitable for subclavian route and is extracted by using transfemoral approach.

Case report

72 year old woman admitted to our clinic with pain and ulcer at pacemaker pocket site. Physical examination revealed vital signs as body temperature 36.5 °C, pulse: 62 beats/min irregular, blood pressure: 120/70 mm Hg, ulceration at pacemaker pocket site and serous drainage from this ulcer. Electrocardiography demonstrated VVI pacemaker rhythm.

History of patient revealed that a VVI pacemaker with passive fixation lead was first implanted in 1997 because of low ventricular rate atrial fibrillation. In 2009 patient underwent pacemaker generator replacement and a second ventricular active fixation lead was implanted because of lead dysfunction in first lead. During the second procedure the first passive fixation lead which is dysfunctional is cut, remaining a short loop length in the pacemaker pocket. In Fig. 1 the Chest X ray demonstrates the implanted pacemaker on right pectoral region and two separate ventricular leads one passive one active fixation.

Patient is admitted to the hospital and after the pacemaker pocket wound and blood cultures are taken antibiotic therapy is started. Transthoracic and transesophageal echocardiographies are performed and they revealed End diastolic diameter: 5.1 cm EF: %60 with no

http://dx.doi.org/mi 016/j.ijcac.2015.07.013

2405-8181/© 2015 The Society of Cardiovascular Academy. Production and hosting by Elsevier B.V. All rights reserved. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Fig. 1. Preprocedural chest X ray.

vegetations on leads or heart chambers. Because the implantation time was over 1 year we decided to perform extraction procedure by mechanic dilator sheath lead extraction system (CookEvolution®). However the first implanted passive fixation ventricular lead's cut point was too deep in the pacemaker pocket region and was left with too short loop to be explored by the subclavian route (Fig. 1). For this reason we decided to extract first implanted lead by using snare from femoral route if needed.

Patient is taken to cardiac catheterization room for the procedure. Procedure is performed under local anesthesia with continuous invasive hemodynamic monitorization and a temporary pacemaker because of pacemaker dependency of the patient. After exploration of pacemaker pocket active fixation lead is removed easily when it is unscrewed by a standard stylet and explanted by simple traction. But the passive lead's remaining proximal site was too deep in the pocket region and could not be explored and captured by subclavian route so we decided to extract lead by femoral approach with help of Byrd Workstation™ 16 F and Needle's eye snare® 12 F. This snare is mostly used as a bail-out procedure to remove the lead or its components which remained in vascular space after an extraction procedure. This is a special snare with two separate snare components with 90° angle to each other, so that the operator can snare the leads components in two different planes at the same time.

Femoral venous access is obtained by Seldinger method and Byrd Workstation™ is placed into the femoral vein. Through this 16 F workstation 12 F Needle's eye snare® is send to capture the right ventricular lead. Passive fixation right ventricular lead is first snared at subclavian site and then at the inferior vena cava region and continuous and gentle traction is applied to the lead (Fig. 2). With this traction the lead is first separated from the superior vena cava region and then the right ventricular myocardium and is extracted by Byrd Workstation™ (Fig. 3). So all the leads and its components are totally removed from the vascular spaces. Because Byrd WorkStation is 16 F in diameter and patient was morbidly obese we preferred vascular surgery to close the femoral vein entry site.

Postprocedural echocardiography is performed and it revealed only minimal pericardial effusion which is not causing cardiac tamponade and the tricuspid valve function was normal. No residual coil or silicone

parts were seen in heart chambers. Patient did not have fever or septic clinic condition, blood cultures and wound cultures demonstrated no signs of infection therefore we implanted new pacemaker to contralateral site three days after extraction procedure. During hospital follow-up no complications occurred and we discharged patient uneventfully.

Discussion

Percutaneous lead extraction indications are infection, pacemaker decubitus, chronic pain at implantation site, thrombosis and venous stenosis, nonfunctional leads and functional leads that are causing a threat to patient if left in its place. Lead extraction devices are mostly designed for subclavian approach but femoral and transjugular approaches are also defined in literature.

Percutaneous femoral lead extraction is mostly done as a bail-out procedure in literature for leads or its components that remained in vascular space after an extraction procedure, however it can be also performed primarily when subclavian route is not a viable option.3,4 In a study which lead extractions are performed primarily by femoral

Fig. 2. Traction applied to snared lead.

Fig. 3. Extracted lead in Byrd Workstation TM16F.

transvenous route with Needle's eye snare® procedural success was % 98.2 in leads which have implantation duration less than 10 years and %93.6 in leads which have implantation duration more than 15 years. It is found that femoral route is especially successful method for atrial and coronary sinus leads.4 This better success in these leads is thought to be the result of less fibrous reaction at atrium and coronary sinus and better transmission of aligned force to distal parts of leads as compared to right ventricular leads. Right ventricular leads are snared at more proximal parts of the lead by the Needles's eye snare and curvature that is formed in right ventricle apex limits traction force when you attempt to remove the lead from right ventricle. The authors also stress that the operator must not simply use snare as pulling device but must push the introducer sheath of snare over the snared lead to perform countertraction. Performing countertraction will help the operator to avoid cardiac avulsion or invagination which may be caused by simple and harsh traction. In our case fortunately lead is extracted by applying only simple gentle traction and we did not have to perform countertraction in which it would have been more difficult to push the introducer at the acute angle toward right ventricular apex. Also Bongiorni et al.5 described an internal transjugular approach which uses first femoral approach then turns to internal jugular vein approach to have better alignment with the lead that is planned to be extracted.

However in this method you have to catheterize both the femoral and jugular veins and snare lead twice for retrieval of the lead.

Regardless ofmethod you use the main principle in lead extraction is the first securely fixing the lead with a locking stylet or snaring the lead at most distal end of its implantation site in myocardium. Second applying properly aligned gentle traction and countertraction forces co-axial to the lead to release it from implantation site without causing avulsion and invagination of cardiac tissue. If lead dysfunction is established and the lead will be left in pacemaker pocket, the operator must be very careful not to damage inner lumen of the dysfunctional lead. The operator must cut the lead at certain distance from subclavian vein entry site with the appropriate remaining loop length which will not prevent future extraction procedures. Bulldog locking stylets can be used for damaged leads but these will allow operator to capture only up to subclavian entry site not the lead's distal tip. As a result the operator will not be able to apply enough traction force to electrode's distal tip and lead's integrity may be damaged, components of the lead may embolize heart chambers or vascular spaces. Also as in our case if the remaining loop of lead is cut at short distance to subclavian venous entry site the operator can not explore lead in pocket and use the subclavian route for extraction. For these reasons in centers which lead extraction is not performed it is important for the operator to know how he will leave the remaining lead loop in pacemaker pocket in case there may be a need for future lead extraction.

If in anyway the subclavian transvenous lead extraction is not possible, femoral transvenous lead extraction may be an effective treatment option for such patients.

References

1. Love CJ, Smith MC. Extraction of pacing leads: overview of current techniques. J Cardiovasc Electrophysiol 2006;17:1-5.

2. Oto A, Aytemir K, Canpolat U, et al. Evolution in transvenous extraction of pacemaker and implantable cardioverter defibrillator leads using a mechanical dilator sheath. Pacing Clin Electrophysiol 2012 Jul;35 (7):834-840.

3. Belott PH. Hands on: lead extraction using the femoral vein. Heart Rhythm 2007;8: 1102-1111.

4. Bracke FA, Dekker L, van Gelder BM. The Needle's Eye Snare as a primary tool for pacing lead extraction. Europace 2013 Jul;15(7):1007-1012.

5. Bongiorni MG, Soldati E, Zucchelli G, et al. Transvenous removal of pacing and implantable cardiac defibrillating leads using single sheath mechanical dilatation and multiple venous approaches: high success rate and safety in more than 2000 leads. Eur Heart J 2008;29:2886-2893.