Scholarly article on topic 'Lead extraction using excimer laser sheath—In full swing even in Japan'

Lead extraction using excimer laser sheath—In full swing even in Japan Academic research paper on "Medical engineering"

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Journal of Cardiology
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{"Lead extraction" / "Excimer laser" / "Cardiac implantable electrical device" / Complications / "Japanese patients"}

Academic research paper on topic "Lead extraction using excimer laser sheath—In full swing even in Japan"

Journal of Cardiology 62 (2013) 201-202

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Lead extraction using excimer laser sheath—In full swing even in Japan*

Keywords: Lead extraction Excimer laser

Cardiac implantable electrical device


Japanese patients

Lead extraction is a necessary procedure for the troubleshooting of cardiac implantable electrical devices (CIEDs) and has increased year on year. It is estimated that 10,000-15,000 leads are extracted annually worldwide, and it is supposed that the reason for the increase in lead extraction is the increase in infection rate of CIEDs [1,2]. Also, extraction for redundant leads has increased recently [3], reflecting both an increasing demand for extraction of these leads and an increasing confidence in extractors. The procedure can be technically complex, and potential complications such as vascular laceration are among the most catastrophic in CIED procedures. In history, various extraction methods have been used: manual traction, extended weight- or forceps-assisted traction, or mechanical extraction systems employing locking stylets and outer sheaths, or open-chest surgery. Laser-assisted lead extraction is one ofthe new desirable methods to be more effective than 'mechanical' methods. The excimer laser sheath (SLSII, The Spectranetics Corporation, Colorado Springs, CO, USA) delivers the laser energy by fiber optics to the distal end of the sheath to release the lead from the encapsulating fibrotic tissue, permitting the advancement of the sheath without excess force or tearing of the tissues. The PLEXES study [4] and LExICon study [5] showed that the addition of the laser sheath significantly improves the efficiency of transvenous lead extraction.

At present, lead extraction using excimer laser is not common in the Asian region, however, it is becoming available in some Asian countries. In the current issue of the Journal of Cardiology, Okamura et al. [6] reported a series of extraction results using excimer laser sheath (SLS II) in Japanese patients in the Kansai area. This may be the first report of Japanese experience in a single center, because SLS II was approved in 2010 in Japan. They reported several important issues. First, they pointed out the differences in physical characteristics between Western and

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* This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-No Derivative Works License, which permits non-commercial use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Asian patients. In the major study of North American patients [5], lower body mass index (BMI) (<25 kg/m2) was associated with an increased risk of procedural major adverse events (MAEs). And also in that study, approximately two-thirds of the patients had high BMI (^ 25 kg/m2). Contrarily, only 10% of patients had a BMI >25 kg/m2 in the Japanese population [6]. Moreover, the success rate of complete removal using SLS II was high (100%) among those patients without major life-threatening complications. Sufficient preparation and agreed procedures following prediction of adhesion site from detailed diagnostic imaging or preoperative team discussion might well have made this possible.

Second, they described the extraction of coronary sinus (CS) lead, in particular StarFix (Medtronic, Minneapolis, MN, USA). They experienced two extraction cases of StarFix without major complications. As is well known, several design features were included on the tip or distal side ofthe CS lead to avoid it being dislodged. StarFix is designed to extend its adjustable wings for fixation within a large branch. When such a designed lead is removed, adjustable wings should be turned back, however, long-implanted leads are usually surrounded by adhesion and fibrotic tissue which block the wings being put back in place. Incomplete return of the wings is a large risk for laceration during extraction. Because the CS and its branch are located dorsal to the heart, it is not easy to repair surgically if the CS was lacerated during extraction. Therefore, extraction of such leads should be performed gently.

Finally, they also described the variation of the access sites for extraction procedures. Commonly, the pocket site should be the appropriate site for percutaneous lead extraction. When access or removal is not possible from the implantation vein, extraction has been achieved by a femoral or jugular venous approach using intravascular catheter-based tools. Various snares, deflecting wires, and grasping means have been deployed via the inferior or superior vena cava to grasp the lead body in the right atrium. Traction and/or countertraction can be applied to free the lead and remove it through the femoral or jugular vein access sheath.

A total CIED removal requires not only intravenous sheath technique, but also surgical ways for exposure of leads and pocket. For example, enough exposure of leads just on the venous access point is useful for easier extraction. Also, in cases of infection, total removal of pocket capsule around the generator or some items such as lead fixation sleeve and strings around them are important for clinical success. Moreover, the strategy to maintain pacing during or after the extraction procedure is important in active infection cases who had been implanted with a cardiac resynchronization therapy pacemaker because of severe heart failure. Okamura et al. [6] described one thought-provoking case (Case 3) that treated epicardial right and left ventricular leads with

Editorial / Journal of Cardiology 62 (2013)201-202

thoracotomy before extraction, and achieved clinical success. Especially in the case of device infection, lead extraction is one part of the total therapeutic strategy, therefore, for complete clinical success, a multidisciplinary approach including surgical methods is needed.

From the standpoint of a multidisciplinary approach, the choice of venue, operating room or electrophysiology (EP) laboratory, for extraction is an important issue. The major published studies of lead extraction have not prescribed or identified yet the optimal site for lead extraction. However, those studies further support the recommendation that if procedures are to be performed in the EP laboratory, rapid-response surgical backup is essential [7] considering that potential complications may be life-threatening. In addition, the Expert Consensus of the Heart Rhythm Society [8] required the "team approach" for the extraction procedure. The extraction team should be made up of several personnel (Table 1) [8]. For the further development of successful lead extraction in Japan and the Asian region, not only physicians and surgeons but all the personnel concerned need to ensure good communication on a routine basis.

Table 1

Required personnel3 [8].

J Primary operator: A physician performing the lead extraction who is properly trained and experienced in device implantation, lead extraction, and the management of complications J Cardiothoracic surgeon well versed in the potential complications of lead extraction and techniques for their treatment, on site and immediately available J Anesthesia support

J Personnel capable of operating fluoroscopic equipment J "Scrubbed" assistant (nurse/technician/physician) J Non "scrubbed" assistant J Echocardiographer

a Depending on the environment, one person can hold expertise in several areas and satisfy the requirements (e.g. the extractor could be the cardiothoracic surgeon), but at least 5 people (1 - airway and sedation management, 2 - scrubbed and 2 -non scrubbed) need to be in the room at all times with the immediate availability of additional personnel as needed.


[1] Hauser RG, Katsiyiannis WT, Gornick CG, Almquist AK, Kallinen LM. Deaths and cardiovascular injuries due to device-assisted implantable cardioverter defibrillator and pacemaker lead extraction. Europace 2010;12: 395-401.

[2] Greenspon AJ, Patel JD, Lau E, Ochoa JA, Frisch DR, Ho RT, Pavri BB, Kurtz SM. 16-Year trends in the infection burden for pacemakers and implantable cardioverter-defibrillators in the United States. J Am Coll Cardiol 2011;58:1001-6.

[3] Kennergren C, BjurmanC, Wiklund R, Gabel J. A single-centre experience of over one thousand lead extractions. Europace 2009;11:612-7.

[4] Wilkoff BL, Byrd CL, Love CJ, Hayes DL, Sellers TD, Schaerf R, Parsonnet V, Epstein LM, Sorrentino RA, Reiser C. Pacemaker lead extraction with the laser sheath: results of the pacing lead extraction with the excimer sheath (PLEXES) trial. J Am Coll Cardiol 1999;33:1671-6.

[5] Wazni O, Epstein LM, Carrillo RG, Love C, Adler SW, Riggio DW, Karin SS, Bashir J, Greenspon AJ, DiMarco JP, Cooper JM, Onufer JR, Ellenbogen KA, Kutalek SP, Dentry MS, et al. Lead extraction in the contemporary setting: the LExICon study. J Am Coll Cardiol 2011;55:579-86.

[6] Okamura H, Yasuda S, Sato S, Ogawac K, Nakajima I, Noda T, Shimahara Y, HayashiT, OnishiY, KobayashiJ, KamakuraS, OgawaH,Shimizu W. Initial experience using excimer laser for the extraction of chronically implanted pacemaker and implantable cardioverter defibrillator leads in Japanese patient. J Cardiol 2013;62:195-200.

[7] Franceschi F, Dubuc M, Deharo J-C, Mancini J, Pagé P, Thibault B, Koutbi L, Prévôt S, Khairy P. Extraction of transvenous leads in the operating room versus electrophysiology laboratory: a comparative study. Heart Rhythm 2011;8: 1001-5.

[8] Wilkoff BL, Love CJ, Byrd CL, Bongiorni MG, Carrillo RG, Crossley GH, Epstein LM, Friedman RA, Kennergren CE, Mitkowski P, Schaerf RH, Wazni OM. Transvenous lead extraction: Heart Rhythm Society expert consensus on facilities, training, indications, and patient management: this document was endorsed by the American Heart Association (AHA). Heart Rhythm 2009;6:1085-104.

Katsuhiko Imai (MD, PhD) * Department of Cardiovascular Surgery, Hiroshima University Hospital, 1-2-3 Kasumi, Minami-ku, Hiroshima 734-8551, Japan

* Tel.: +81 82 257 5216; fax: +81 82 257 5219. E-mail address:

31 May 2013 Available online 11 July 2013