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• W4313201568 abstract "Transvenous lead extraction (TLE) is essential in the long-term management of cardiac implantable electronic devices and most procedures are safe and successful (1Starck C.T. Gonzalez E. Al-Razzo O. Mazzone P. Delnoy P.P. Breitenstein A. et al.Results of the Patient-Related Outcomes of Mechanical lead Extraction Techniques (PROMET) study: a multicentre retrospective study on advanced mechanical lead extraction techniques.EP Eur. 2020 May 23; (euaa103)Google Scholar). Current techniques rely on advancing sheaths over a targeted lead reinforced by a locking stylet; in the event of failure, the femoral approach is often utilized to complete the procedure in a ‘bail-out’ (2Byrd C.L. Schwartz S.J. Hedin N. Intravascular techniques for extraction of permanent pacemaker leads.J Thorac Cardiovasc Surg. 1991 Jun; 101: 989-997Abstract Full Text PDF PubMed Google Scholar). This does not guarantee success. The femoral approach in conjunction with a jugular approach has been used effectively and safely in difficult cases, pulling the lead downward and then upward (3Bongiorni M.G. Soldati E. Zucchelli G. Di Cori A. Segreti L. De Lucia R. 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 Oct 30; 29: 2886-2893Crossref PubMed Scopus (190) Google Scholar)(4), but the method described by Bongiorni et al. is incompatible with the use of locking stylets and so is not routinely used with powered sheaths. The jugular vein has significant advantages: the distance from the access point to the heart is significantly shorter from the jugular than the femoral, and the course from access point to right ventricular apex is straighter from the jugular than from any other access. We describe a novel technique used to transfer the targeted lead from the original subclavian access to the right jugular vein with a deployed locking stylet in-situ. In this case it allowed us to complete the extraction of a high-voltage lead that had resisted extraction by standard methods. A 55 years-old man with a background of Hypertrophic Cardiomyopathy (HCM) and dual chamber implantable cardioverter defibrillator (ICD) for primary prevention, was admitted after multiple inappropriate shocks due to electrical artefact on the right ventricle (RV) high voltage lead (DX system, BIOTRONIK, Berlin, Germany). The RV lead had been implanted elsewhere 5 years earlier and an atrial lead added to permit atrial pacing 6 months before presentation. The patient was scheduled for extraction and replacement of the ICD system using a “Tandem” approach. Following induction of general anesthesia, a 13-mm Needle’s Eye Snare (NES) was advanced from the right femoral vein to the right atrium. The device was freed from its left pre-pectoral pocket; the leads were dissected free, and the atrial lead was removed by gentle traction. After retracting the fixation helix of the RV lead, a locking stylet (Liberator Beacon Tip, Cook Medical, IN, USA) was deployed and a compression coil was applied (OneTie, Cook Medical, IN, USA). An obstruction at the entrance to the shock coil prevented the locking stylet from reaching the lead tip. The NES was used to grasp the lead in the RA and provide countertraction as the 13-Fr Evolution RL (Cook Medical, IN, USA) was advanced over the lead (figure 1). Upon reaching the RA, the lead was released from the snare to allow the dissecting tool to advance, but the lead began to unravel at the coil, halting any further advancement. The lead was repeatedly re-grasped with the snare in attempts to complete the extraction femorally, but the disrupted coil prevented lead from entering the outer sheath of the snare and moderate traction could not move the lead tip. The right internal jugular (RIJ) vein was accessed using a 20-Fr sheath (Cook Medical, IN, USA) and a 25-mm Gooseneck snare (Medtronic, MN, USA) was passed through it to the SVC whilst the Evolution outer sheath preserved the subclavian vein access. A 0.032 guidewire (Abbott Medical, IL, USA) was passed through the Evolution outer sheath in the subclavian to the superior vena cava (SVC) where it was snared by the Gooseneck and pulled out through the jugular sheath. A long 8.5F sheath (SL0, Abbott Medical, IL, USA) was advanced over the 0.032 wire through the jugular sheath, into the Evolution outer sheath alongside the targeted lead, and emerge from the sheath at the subclavian access site. The dilator of the SL0 sheath was removed leaving the sheath to act as a tunnel connecting the jugular to the left subclavian access point. Via this tunnel, the 25-mm Gooseneck snare catheter was passed from the jugular site to surface at the subclavian side where it was used to ‘collect’ the free end of the locking stylet, and pull it through to exit at the jugular site (figure 2). The locking stylet, now at the jugular end, was grasped and used to pull the mobile segment of the lead into the SL0 sheath. Then the entire unit of SL0, locking stylet and lead, was pulled smoothly at the jugular access, transporting the stylet/lead unit safely from the subclavian site to emerge intact through the 20-Fr jugular sheath. With the targeted lead now exiting the RIJ, the 13-Fr dissecting sheath was advanced over it to the lead tip and the lead was extracted in its entirety. Access was retained and a new dual chamber ICD was implanted without sequalae. We describe a novel subclavian-to-jugular pull-through technique which provided a safe and effective method for transferring a lead and locking stylet, as a unit, from the subclavian access point to the jugular (video; figure 3). It represents an adaptation of the Bongiorni technique that allows a locking stylet to remain fully deployed in the lead and usable after the transfer of access site. In this case, the transfer to the jugular was key to successfully completing the extraction. Switching to the RIJ straightened the lead, allowing previously impossible progress of the Evolution sheath to apply counter-pressure at the lead tip. Owing to the angulated course of the lead, sheaths of similar size advanced from the subclavian or the femoral had made no progress. Traction applied to a lead permits a dissecting tool to follow that lead through the tortuosity of the vasculature (5Akhtar Z, Sohal M, Starck CT, Mazzone P, Melillo F, Gonzalez E, et al. Persistent left superior vena cava transvenous lead extraction: A European experience. J Cardiovasc Electrophysiol. 2021 Nov 22;jce.15290.Google Scholar). From the subclavian access, the angulations passed to reach the ventricular apex are considerable. A locking stylet, particularly when combined with fixation of the lead in the atrium in the “Tandem” approach, permits enough force to overcome most of the tortuosity in the majority of cases. The enhanced countertraction from the “Tandem” may also pull the lead away from the SVC wall, reducing cardiovascular injury (6Muhlestein J.B. Dranow E. Chaney J. Navaravong L. Steinberg B.A. Freedman R.A. Successful avoidance of superior vena cava injury during transvenous lead extraction using a tandem femoral-superior approach.Heart Rhythm. 2022 Mar 1; (00209-0): S1547-5271PubMed Google Scholar), but the technique only helps as far as the right atrium. From the right atrium to point of RV lead attachment, one additional angle must be crossed without the assistance of the snare. The linear course from jugular to RV apex can help; transferring the lead to the jugular vein, reduces this last angle. For leads attached in the RV outflow tract, a femoral approach would provide more favorable angles, but the current powered sheaths are not adapted to this application. The jugular approach has historically been applied to free floating leads or leads that are converted to ‘free floating’ by pull-down from the femoral vein (3Bongiorni M.G. Soldati E. Zucchelli G. Di Cori A. Segreti L. De Lucia R. 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 Oct 30; 29: 2886-2893Crossref PubMed Scopus (190) Google Scholar)(4). Leads with a fully deployed locking stylet cannot safely be rendered free floating; the handle end of the device is designed for heavy work outside the body, not exposure to endovascular surfaces. Our jugular pull-through technique was adapted from the Bongiorni technique via the ‘triple venous access’ method (7Akhtar Z, Zaman KU, Leung LW, Zuberi Z, Sohal M, Gallagher MM. Triple access transvenous lead extraction: Pull‐through of a lead from subclavian to jugular access to facilitate extraction. Pacing Clin Electrophysiol. 2022 Jun 17;pace.14547.Google Scholar) and overcomes these limitations. The use of the SL0 sheath to act as the transfer vehicle between the jugular and subclavian veins was crucial – it protected the vessels from injury by exposed metal. The length of the SL0 was also valuable as it ensured that the two ends of the sheath remained externalized. This allowed control of the ‘vehicle’ and ensured that the full length of the locking stylet was engulfed within the sheath. The 8.5F internal diameter of the SL0 was sufficient to contain the end of this high-voltage lead and transport it from one access to the other. Larger sheaths of similar length are available. The advantage of the subclavian-to-jugular pull-through over the Bongiorni method is that it permits transfer of a fully deployed locking stylet from one access to the other. The locking stylet remains usable and provides the length and enhanced tensile strength to help the passage of a dissecting tool over the lead, and to limit lead disintegration (8Vatterott P. De Kock A. Hammill E.F. Lewis R. Strategies to increase the INGEVITY lead strength during lead extraction procedures based on laboratory bench testing.Pacing Clin Electrophysiol. 2021 Aug; 44: 1320-1330Crossref PubMed Scopus (1) Google Scholar). Conventionally, the locking stylet is deployed early in a procedure; from that point, abandonment of the procedure or conversion to another access site becomes difficult as the stylet is not always easy to remove. Our technique provides a route to overcome this limitation. It permits the operator to use their conventional extraction approach with confidence, always retaining the option of switching to the jugular, if the need arises. In this case we used a 20-Fr sheath for jugular access, a sheath that proved too small to allow the passage of the 13-Fr Evolution outer sheath. We therefore had to remove this sheath and pass the Evolution tool directly through the skin. The size of the access channel prepared by the 20-Fr sheath made this reasonably easy. In other cases, we have used a 23-Fr jugular sheath and have found that the outer sheath of the 13-Fr Evolution passed through without difficulty; the 23-Fr sheath is a more elegant solution but was unavailable on the day of the case described. The de-spiraling of the shock coil in this case could be interpreted as evidence of rough handling either in the form of excessive traction or excessive compression by the needle eye snare. We do not believe that either of these occurred; we take the electrical malfunction of the lead, the apparent obstruction encountered by the locking stylet and the de-spiraling at the same point as evidence of prior lead damage at this site. By the time it had been removed the lead was too damaged to test this hypothesis. The pull-through of this lead added to the long procedural and fluoroscopy time, so the technique is not suitable for widespread routine use. In this case, repeated unsuccessful attempts to extract the lead by conventional means had already consumed a lot of time, and we might have succeeded sooner if we had switched to this approach earlier. This technique requires at least two operators with experience in TLE which may not be possible in low volume centres. This technique was utilized as a ‘bail-out’ in our case but could be used as a method of choice in selected difficult cases which may include leads with a very prolonged dwell time, leads that are prone to disintegration or patients with unfavorable anatomy. The subclavian to jugular pull-through technique enables safe transfer of lead and stylet from the subclavian to the jugular access to facilitate complete lead extraction. It was used as a ‘bail-out’ option in our case but has potential for wider application." @default.
• W4313201568 created "2023-01-06" @default.
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• W4313201568 date "2023-03-01" @default.
• W4313201568 modified "2023-10-18" @default.
• W4313201568 title "Transvenous lead extraction: The subclavian-to-jugular pull-through technique" @default.
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