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- femoral “drag through” technique
- permanent pacemaker lead extraction
- implantable cardioverter-defibrillator
The development of specialised equipment has allowed permanent pacemaker lead extraction using minimally invasive techniques,1, 2 but despite this the major complication rate is approximately 1–3%.1, 2 One reason for this is that the fragile subclavian vein, superior vena cava, and right atrium may tear during the process of cutting away the fibrous tissue that enfolds the leads in these regions. Drawing the body of the lead, which has the narrowest profile (cf. the tip and electrodes), through this fibrous sleeve from below, using a femoral approach, avoids the need for this dissection. Furthermore, the dissection required when using a superior approach to expose the subclavian vein can be painful and time consuming. When using a femoral approach only superficial dissection to free the leads and remove the suture sleeves is required and therefore the procedure can be performed under local anaesthetic. The major disadvantage of the femoral approach is that it does not provide access for a replacement lead. This study investigated the feasibility of a modification to conventional femoral lead extraction, providing venous access for introduction of a new pacing/implantable cardioverter-defibrillator (ICD) lead along the channel occupied by the extracted lead.
Any patients requiring lead extraction and immediate replacement of an ipsilateral pacing/ICD system were considered suitable for lead replacement using a “drag through” technique. Patients considered unsuitable were those in whom there was evidence of lead infection, or crushing of the lead between the clavicle and the first rib, reflecting a suboptimal implantation route.
Lead extraction procedure
The procedure was performed under local anaesthetic (with two exceptions, see table 1) with additional analgesia at the patient's request. Venography was performed on the ipsilateral side and a temporary pacing wire was inserted via the left femoral vein. The generator was removed, the lead(s) requiring extraction cut, freed to the retaining sleeves/sutures, and the sutures removed. A 16 French sheath was inserted in the right femoral vein and either a basket and deflecting wire (Byrd femoral workstation) or a needle-eye-snare were introduced (Cook UK, Ltd). A normal stylet was advanced into the pacing/ICD lead before being snared in order to preserve the lumen. As soon as the lead was grasped this stylet was removed.
The drag through technique was then performed by cutting the pacing/ICD lead leaving 1 inch (2.5 cm) exposed. The outermost electrode coil of the lead was then grasped with an artery clip and pulled out from the lead insulation. The coil was then cut at the external insulation, so the coil inside the insulation was partially unwrapped, leaving a space between the external insulation and the outer coil. A 140 cm 0.35 inch J tipped guide wire was then introduced into the gap left between the coil and the insulation and pushed in until it was firmly attached (fig 1 inset). The proximal end of the lead was then pulled down into the right atrium from below while the guide wire was fed in behind. When the proximal lead/guide wire join reached the level of the right atrium the guide wire was fixed and the lead pulled so that the two separated (fig 1).
The lead was then extracted using previously described conventional counter-traction techniques.1 The guide wire was then used to introduce a 23 cm “peel-away” sheath (Daig Inc, Minnesota. USA) through which a replacement lead was then passed.
Outcomes of the lead extraction were based on previously published recommendations.3 Complete success was defined as removal of all material from the vascular space. Partial success was defined as removal of all but a small portion of the lead. Clinical success was defined as achievement of all clinical goals associated with the indication for lead removal.
A total of 36 consecutive patients (22 male, mean (SD) age 63 (14) years) underwent extraction of 63 leads which had been in situ for 7.8 (4.6) years (7.3 (3.3) years for drag through patients). Nineteen patients had infected systems, one patient required radiotherapy for breast carcinoma on the ipsilateral side, one patient had a long section an active fixation lead floating free in the right atrium following a failed attempt to extract it from the superior approach at another centre, and one patient had a crush fracture between the clavicle and first rib. Therefore, 14 patients were suitable for lead extraction and immediate replacement of their system, four of whom required extraction of an old pacing/ICD system in order to implant an ICD. The indications for lead extraction in the remaining patients were lead failure in young patients (≤ 60 years) (n = 4), Telectronics Accufix lead removal requested by patient (n = 2), and venous occlusion (n = 4).
Leads were extracted using a Byrd femoral workstation in six patients and a needle eye snare in eight patients (table 1). Clinical success was achieved in 100% of leads with 86% patients (91% leads) having complete success. Partial success resulted from retention of the distal 2 cm of the lead (n = 2 leads). Achieving venous access via the drag through technique was successful in all patients and was used to extract and replace 20 pacemaker/ICD leads. The drag through technique was successfully used in the eight patients with multiple leads. Two patients had three leads removed, including two previously abandoned ventricular leads, and six patients had one lead extracted only (five ventricular, one atrial) with functioning pre-existing leads left undisturbed. A single guide wire was dragged through and used to introduce two sheaths, allowing upgrade from a single chamber to a dual chamber pacemaker in one patient, otherwise individual guide wires were introduced for each lead being replaced. Two lead extraction procedures were performed under general anaesthetic (14.3%) because of concurrent ICD implantation. The pacemaker lead drag through including reimplantation procedure times were 155 (71) minutes and 41 (28) minutes. Mean stay in hospital was 1.5 (1.1) days.
Permanent pacemaker lead extraction has major complication rates of 1.4%1 and the results are similar using laser assisted lead extraction with major complication and mortality rates of 3.2% and 0.6%.2 Although there is some theoretical advantage to femoral lead extraction, one limitation is that there is no vascular access for implantation of a new system. This is of particular relevance in those patients with subclavian or brachiocephalic vein occlusions, which occurs in up to 12% of patients with permanent pacemakers.4 Lead extraction and replacement of the lead on the same side as a vein occlusion avoids the possibility of bilateral subclavian occlusions, failure to cross a superior vena cava, or the need to implant a femoral system. Recent reports have demonstrated that replacing pacemaker leads through occluded veins is possible, particularly when using a laser assisted approach.5 This study has demonstrated that replacement of both permanent pacing and ICD leads is possible using the cheaper femoral approach, even when the veins are occluded. This was achieved without complication and was performed under local anaesthetic in most cases.
Cannulation of the veins used by non-functioning pacemaker/ICD leads can be achieved using the drag through technique after lead extraction by the femoral approach. This allows introduction of new leads even through occluded veins.