Introduction
Transvenous lead extraction (TLE) is integral to the management of cardiac implantable electronic devices (CIEDs) (1). Percutaneous techniques have advanced considerably over the last 20-30 years. Initial methods relied on the application of traction with simple dissecting sheaths and when this failed, the femoral approach was utilized for completion (2). The jugular access was demonstrated to be an effective and safe approach by Bongiorni et al; the jugular vein provides a short and linear path to the heart. Their internal transjugular approach (ITA) involved femoral pull-down of the targeted lead before being pulled-up via the internal jugular vein for extraction (3,4). This technique however is incompatible with locking stylets and therefore rarely used with powered extraction tools.
We describe a novel technique used to transfer a lead with a fully deployed locking stylet from the subclavian access to the right internal jugular (RIJ) vein to complete the extraction using a mechanical powered sheath.
Case
A 55 years-old gentleman with an implantable cardioverter defibrillator (ICD) was admitted to hospital for multiple inappropriate shocks secondary to lead ‘noise’. His background included Hypertrophic cardiomyopathy (HCM) with the ICD implanted for primary prevention 5-years earlier using a single coil high-voltage lead. He was listed for an urgent extraction and replacement of the ICD system.
After induction of general anesthesia (GA), we employed the ‘Tandem’ technique. The device was dissected free at the left pre-pectoral pocket and the lead was mobilized. After retracting the fixation helix of the lead, a locking stylet (Liberator Beacon Tip, Cook Medical, IN, USA) was deployed but an obstruction at the shock coil prevented this from reaching the lead tip. Accepting this, a compression coil was applied (OneTie, Cook Medical, IN, USA) to reinforce the lead-locking stylet rail. A 13-mm Needle’s Eye Snare (NES) (Cook Medical, IN, USA) was then advanced from the right femoral vein, to grasp the lead in the right atrium (RA) and provide countertraction as the 13-Fr Evolution RL (Cook Medical, IN, USA) was advanced over the lead (figure 1). As the dissecting sheath reached the RA, the lead was released from the NES to permit further sheath advancement towards the lead tip. However, the lead coil began to unravel inhibiting any further progress. Attempts to extract the lead from the femoral approach also failed; the disrupted coil obstructed the lead from entering the sheath and traction could not free the lead tip from its attachment. A decision to attempt extraction via the jugular vein was made.
A 20-fr sheath (Cook Medical, IN, USA) was positioned in the RIJ vein and a 25-mm Gooseneck snare (Medtronic, MN, USA) was passed through it to sit in the superior vena cava (SVC); the Evolution outer sheath retained the subclavian vein access. A 0.032 guidewire (Abbott Medical, IL, USA) was passed through the Evolution outer sheath (subclavian) to the SVC where it was snared and pulled out through the jugular sheath by the Gooseneck.
