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How To Do Lead Extraction How To Do Lead Extraction Using The Femoral Vein :Using The Femoral Vein :
Benefits and ComplicationsBenefits and Complications
Peter Belott FACC FHRS
Femoral Approach to Lead Femoral Approach to Lead Extraction , Benefits and Extraction , Benefits and
Complications : Internal Jugular Complications : Internal Jugular Approach to Lead Extraction , is Approach to Lead Extraction , is
the Extra Effort Worth the the Extra Effort Worth the Results?Results?
Peter H Belott MD FACC FHRS
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DisclosuresDisclosures
• Consulting fees/honorarium• Blackwell Publishing,Cameron Health
Corp,Guidant / Boston Scientific Corp,St Jude Medical Corp,Cardiodynamics Inc , SpectraneticsInc , Peak Surgical Corp.
• Speakers Bureau• Guidant / Boston Scientific Corp ,St Jude Medical
Corp• Research Grants
• Guidant / Boston Scientific ,St Jude Medical• Equity interest/stock options
• None
FEMORAL APPROACHFEMORAL APPROACH
“INFERIOR APPROACH” ???
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FEMORAL APPROACH :FEMORAL APPROACH :INDICATIONSINDICATIONS
• Failed Superior Approach• Primary Approach
History of Lead ExtractionHistory of Lead Extraction• Past: Traction applied by weights,
elastic bands, or other inventive methods• Dangers:
• PVCs• Life-Threatening Arrhythmias• Potential Eversion of the RV
Apex• Lead disintegration
• Traction relies on tensile strength of lead insulation and conductor coils
• Leads implanted for < 6 months could be removed with traction alone.
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Espinoza ,Hayes,Vliestra . PACE 16 ,1993
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EXTRACTION USING THE EXTRACTION USING THE FEMORAL VEINFEMORAL VEIN
• BYRD FEMORAL WORK STATION• SNARE TECHNIQUES
Inferior ApproachInferior Approach
• Deflecting Wire and Dotter• Curry Loop Snare• Amplatz Snare• The Needles Eye
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TRANSVENOUS LEAD TRANSVENOUS LEAD EXTRACTION:EXTRACTION:
HEART RHYTHM SOCIETYHEART RHYTHM SOCIETYEXPERT CONSENSUSEXPERT CONSENSUS
ONONFACILITIESFACILITIES
TRAINING,INDICATIONS ANDTRAINING,INDICATIONS ANDPATIENT MANAGEMENTPATIENT MANAGEMENT
HEART RHYTHM :HEART RHYTHM :VolVol 6 # 7 JULY 20096 # 7 JULY 2009
• Definitions• Extraction Tools• Defining Outcomes• Defining Complications• Lead Management Environment• Personnel ,Qualifications,Training• Indications• Registry and Data Management
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Personnel, Facility, and Equipment Personnel, Facility, and Equipment RequirementsRequirements
Tools For Lead Preparation Tools For Lead Preparation
• Lead Cutter • Coil Expander• Soft Grip Hemostat• Locking Stylets• Special Stylets (801)
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MINIMAL FACILITY MINIMAL FACILITY REQUIREMENTSREQUIREMENTS
• FACILITY• SUPPORT PERSONNEL• EXTRACTION TEAM• EQUIPMENT
EXTRACTION FACILITYEXTRACTION FACILITYOPERATING ROOMOPERATING ROOM
CATH LABCATH LAB
• PHYSIOLOGICAL RECORDERS• MINOR SURGICAL TRAY• ECHO / TEE• ELECTROCAUTERY• PERICARDIALCENTESIS TRAY
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MONITORING,PACEMAKER MONITORING,PACEMAKER ICD AND SURGICAL ICD AND SURGICAL
INSTRUMENTSINSTRUMENTS
• ECG• ARTERIAL LINE• OXIMETRY• PACEMAKER /ICD-PROGRAMMERS• PM /ICD SPARE PARTS
• MINOR SURGICAL TRAY• STERNAL SAW• THORACOTOMY TRAY• DRAINAGE SYSTEM• PERICARDIALCENTESIS• TEMPORARY PACING• ECHO-TEE
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Femoral Lead ExtractionFemoral Lead Extraction
• Failed superior approach • Broken leads• Floating free ends
Byrd Femoral Work StationByrd Femoral Work Station
• Byrd femoral Sheath• Deflecting wire and handle• Amplatz snare• Curry snare
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BYRD FEMORAL WORK STATION
BYRD FEMORAL WORK STATION
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Byrd Femoral Work StationByrd Femoral Work Station
BYRD WORK STATIONBYRD WORK STATION
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AmplatzAmplatz SnareSnare
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AmplatzAmplatz SnareSnare
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AmplatzAmplatz SnareSnare
DOTTER and DEFECTING WIRE
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Femoral Approach PrepFemoral Approach Prep
• 18 Gauge Thin Wall Needle• Byrd Femoral Work Station• Sterile IV Tubing • Heparinized Flush
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Deflecting Wire and Dotter Deflecting Wire and Dotter RetrieverRetriever
• No Free End• Potentially Irreversible
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••Deflecting Wire and DotterDeflecting Wire and Dotter
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CURRY SNARECURRY SNARE
FREE ENDS
Curry Loop SnareCurry Loop Snare
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Curry SnareCurry Snare
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Curry SnareCurry SnareFree endFree end
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Deflecting Wire /Catheter/Deflecting Wire /Catheter/AmplatzAmplatz
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Deflecting Wire /Catheter/Deflecting Wire /Catheter/AmplatzAmplatz
AmplatzAmplatz SnareSnare
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Byrd Femoral Work StationByrd Femoral Work Station
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Snaring Lead TipSnaring Lead Tip
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THE NEEDLES EYETHE NEEDLES EYE
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CASE # 1CASE # 1
• 83 y/o Female s/p AICD with Endotaktransvenous lead -1990
• AICD IPG CHG – 2004• Pocket revision,AICD removal and new
AICD right pectoral area -3.29.04• Multiple revisions left chest including
removal of subcutaneous patch
• Continuous draining from wound with electrode remnant in left pectoral area
• Patient referred for removal of Endotaklead
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WoundWound
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• Proximal lead remnant prepared
• Locking styletapplied
• 16 french laser sheath with outer teflon sheath advanced over the ICD lead
The Distal Coil BrokeThe Distal Coil Broke
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ATTEMPT TO RETRIEVE FROM ATTEMPT TO RETRIEVE FROM BELOWBELOW
• Byrd Femoral workstation• Deflecting wire • Amplatz snare
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Arrangements Made for Open Arrangements Made for Open Heart SurgeryHeart Surgery
• Extract AICD lead Remnant• Reposition Atrial lead• Reposition AICD lead
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LessonsLessons
• The ICD lead like barbed wire• Never take anything for granted• ICD lead can be very difficult and
Challenging
CASE : 2CASE : 2
• 75 y/o s/p DCP 12/2/98 CHB• S/P new atrial wire • Upgrade to BiV AICD 11/2005• Draining pocket 2/2006
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Snaring with Snaring with AmplatzAmplatz and and Deflecting WireDeflecting Wire
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5 LEADS5 LEADS• Chronic Atrial #1-• Chronic Atrial # 2-• Chronic Ventricular• Recent RV AICD Lead• Recent LV lead
IssuesIssues
• INFERIOR APPROACH REQUIRED• LV LEAD EXTRACTION• INFECTION ISSUES• CHF REIMPLANTATION OF BIV• TEMPORARY PACING
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64 S/P BIVAICD 200464 S/P BIVAICD 2004
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CASE : BIV AICD CASE : BIV AICD RECURRENT SEPSISRECURRENT SEPSIS
• 73 y/o s/p Pacemaker 2003• AVN Ablation 2003 - AF• Coagulase neg Staph Infection 2004• AICD 2005 on right• Erosion on Left - IPG Removed • Removal of BIV AICD + 5 Leads
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Cut Left Sided LeadsCut Left Sided Leads
Lessons Lessons
• Don’t Pull on leads • Don’t Cut Abandon Leads
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Boone Extraction 32910Boone Extraction 32910
• 36 y/o s/p DDD 1999• Left sided infection 2008• New right sided system 2008• Leads cut and burried• Continuous drainage 11/2009• Retained leads removed 32910
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52 52 y/oy/o with NIDCM ,CRF on with NIDCM ,CRF on dialysis S/P AICD 1/5/05 with dialysis S/P AICD 1/5/05 with MDT 6949 Lead ,referred for MDT 6949 Lead ,referred for removal of the ICD System removal of the ICD System because of because of StaphStaph AureusAureus
sepsissepsis
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CXRCXR
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••Director of Cardiovascular Director of Cardiovascular Division Division
••University Hospital of Pisa (I)University Hospital of Pisa (I)
••Lead ExtractionLead Extraction••Pisa ApproachPisa Approach
••Maria Grazia Bongiorni, MDMaria Grazia Bongiorni, MD
TRANSVENOUS LEAD REMOVALTRANSVENOUS LEAD REMOVAL
THE INTERNAL TRANSJUGULAR APPROACHTHE INTERNAL TRANSJUGULAR APPROACH
Lead Extraction - Pisa Approach
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NEED OF JUGULAR APPROACHNEED OF JUGULAR APPROACH
Narrow costoNarrow costo--clavicular spaceclavicular spaceTightness of binding sites at various sitesTightness of binding sites at various sites
Superior vena cavaSuperior vena cavaAtriumAtriumTricuspid valveTricuspid valveVentricleVentricle
Lead damage (no stylet)Lead damage (no stylet)
Venous Entry ApproachVenous Entry Approach
Tightness of binding sitesTightness of binding sitesTricuspid valveTricuspid valveVentricleVentricle
Femoral ApproachFemoral Approach
Lead Extraction - Pisa Approach
TRANSVENOUS LEAD REMOVALTRANSVENOUS LEAD REMOVAL
THE INTERNAL TRANSJUGULAR APPROACHTHE INTERNAL TRANSJUGULAR APPROACH
Lead Extraction - Pisa Approach
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TRANSVENOUS LEAD REMOVALTRANSVENOUS LEAD REMOVAL
THE INTERNAL TRANSJUGULAR APPROACHTHE INTERNAL TRANSJUGULAR APPROACH
Lead Extraction - Pisa Approach
TRANSVENOUS LEAD REMOVALTRANSVENOUS LEAD REMOVAL
THE INTERNAL TRANSJUGULAR APPROACHTHE INTERNAL TRANSJUGULAR APPROACH
Considering the outcome of the jugular approach for free-floating leads, since 1997 we performed this approach in case of failure of Venous Entry Approach.
Lead Extraction - Pisa Approach
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TRANSVENOUS LEAD REMOVALTRANSVENOUS LEAD REMOVAL
Exposed unextracted
leads
Internal Transjugular
Approach
THE INTERNAL TRANSJUGULAR APPROACHTHE INTERNAL TRANSJUGULAR APPROACH
Lead Extraction - Pisa Approach
Single Sheath TechniqueSingle Sheath Technique
Personal Experience on Lead ExtractionPersonal Experience on Lead Extraction
Lead Extraction - Pisa Approach
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Lead Extraction - Pisa Approach
Copyright restrictions may apply.
Bongiorni, M. G. et al. Eur Heart J 2008 0:ehn461v1-8; doi:10.1093/eurheartj/ehn461
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Bongiorni, M. G. et al. Eur Heart J 2008 0:ehn461v1-8; doi:10.1093/eurheartj/ehn461
THE INTERNAL JUGULAR APPROACHTHE INTERNAL JUGULAR APPROACH
METHODS: The proximal end of the lead is cutted; the lead is caught by the tip deflecting wire introduced via the femoral vein; the lead runs through the adherences and is made free-floating
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Copyright restrictions may apply.
Bongiorni, M. G. et al. Eur Heart J 2008 0:ehn461v1-8; doi:10.1093/eurheartj/ehn461
THE INTERNAL JUGULAR APPROACHTHE INTERNAL JUGULAR APPROACH
METHODS: The proximal end of the lead is caught by the lassos and the lead is then exposed through the Internal Jugular vein
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Copyright restrictions may apply.
Bongiorni, M. G. et al. Eur Heart J 2008 0:ehn461v1-8; doi:10.1093/eurheartj/ehn461
THE INTERNAL JUGULAR APPROACHTHE INTERNAL JUGULAR APPROACH
METHODS: A standard procedure is performed by using mechanical sheaths
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Personal experiencePersonal experience
Right Superior Venous Entry
Internal TransjugularApproach
Arrhythmology Unit – CardioThoracic Department AOUP – Pisa, Italy
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Mechanical – Laser – EDS TechniquesYears Complete Partial Failure MajorImplanted Success Success Complication
Mechanical (1994 – 1996) 12338 Patients 4,3 + 3,8 93% 5% 2% 1,4% 3540 LeadsLaser (1996 – 1998) 21463 Patients 6,5 + 4,2 90% 3% 7% 1,9%2249 LeadsElectrodissection (1999 - 2001) 3265 Patients 7,5 95.9% 3.5% 0.6% 2,6%542 Leads
Personal Data (1997 – 2007) 4
1192 Patients 69.3(1-336) 98.4% 0.9% 0.6% 0,7%2065 Leads
1Byrd CL. PACE 1999 2Reiser C. PACE 1998 3 Byrd CL. NASPE 2001 4Bongiorni. Eur Heart J 2008
Lead Extraction - Pisa Approach
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CONCLUSIONSTransvenousTransvenous lead extraction is today an effective and lead extraction is today an effective and relatively safe procedurerelatively safe procedure
The success rate and the incidence of complications The success rate and the incidence of complications are highly affected by the experience, techniques and are highly affected by the experience, techniques and materialsmaterials
The Internal Jugular Approach enhances the effectiveness of the procedure with very low risk of major complications.
The procedure and approaches must be well planned and, on occasion, tailored to the single case.
Is the extra effort Is the extra effort worth the results ?worth the results ?
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FEMORAL LEAD EXTRACTIONFEMORAL LEAD EXTRACTION““INFERIOR APPROACHINFERIOR APPROACH”” ??
SAFERSAFER• Less Risk of Perforation• Less Risk of Vascular Laceration• Less Risk RV Avulsion and Tamponade• Control
FEMORAL VENOUS FEMORAL VENOUS APPROACHAPPROACH
• IMPORTANT • LIMITED APPLICATION• SAFE
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““REVERSIBILITYREVERSIBILITY””
Factors influence the Outcome of Factors influence the Outcome of Transvenous LeadTransvenous Lead--ExtractionExtraction
1. CLINICAL FACTORS1. CLINICAL FACTORS 3. TOOLS FOR EXTRACTION3. TOOLS FOR EXTRACTIONImplant Duration Simple tractionMultiple Leads Snare, Catcher, LassosAge and Gender StyletsPM/ICD leads Mechanical, Laser, RF Sheaths
2. MECHANICAL CHARACTERISTICS2. MECHANICAL CHARACTERISTICS 4. VENOUS APPROACHES4. VENOUS APPROACHESAdhesion Venous EntryApproachCalcifications Femoral ApproachVegetations Jugular Approach Fracture of leadProtrusionInsulation Failure 5. PHYSICIANS EXPERIENCE5. PHYSICIANS EXPERIENCEDamage from unsuccessfull attempts
Lead Extraction - Pisa Approach
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1. Venous Entry Approach: using the implant vein1. Venous Entry Approach: using the implant vein
2. Inferior Approach or Femoral Approach2. Inferior Approach or Femoral Approach
3. Internal Jugular Approach (personal technique from 3. Internal Jugular Approach (personal technique from ‘‘97)97)
Transvenous Lead Extraction Approach
Lead Extraction - Pisa Approach
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IPG CHG 2003,Continuous Draining SinusIPG CHG 2003,Continuous Draining Sinus
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PACEMAKER INFECTION PACEMAKER INFECTION
AND EROSION(0.7-1.0%)
PULSE GENERATOR PULSE GENERATOR CHANGESCHANGES
• OBLITERATE THE POCKET• DISSECT AWAY ENCAPSULATING
FIBROUS SCAR• REMOVE EXTRANEOUS MATERIAL• CREATE A NEW PLANE• CONSIDER SUBPECTORAL
PLACEMENT
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DebrideDebride! ! DebrideDebride! ! DebrideDebride!!
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JP DRAINJP DRAIN
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Primary ClosurePrimary Closure
COMPLICATIONSCOMPLICATIONS
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WHAT CAN MAKE FUTURE WHAT CAN MAKE FUTURE EXTACTIONS EASIER AND EXTACTIONS EASIER AND
SAFESAFE
• NEW LEAD DESIGN - EPTFE COATING• DON’T PULL THE LEAD (S)• DON”T CUT THE LEADS• ICD SINGLE COIL• KNOWLEDGE OF THE HARDWARE
CONCLUSIONSCONCLUSIONS
• SAFE- EXPERIENCE /PREPARATION• DEDICATED CENTER• TOOLS• CVS BACK UP• PATIENT SELECTION• KNOW WHEN TO STOP!
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