The “rope and stick” and the “safety snare”: Two new techniques for tricky lead extractions

Abstract

A 77-year-old pacemaker-dependent male was referred to our institution for extraction of a single-chamber pacing system for device infection. He received in 1998 a dual-chamber pacemaker with two passive leads (Pacesetter membrane-E 1450 T/1420 T) for complete atrio-ventricular block. After device-replacement he developed a pocket infection managed with antibiotic, removal of the device and excision of almost all the extravascular portion of the two leads and re-implant of a single-chamber device (year 2009) on the opposite site (the patient was in permanent atrial fibrillation). After many local revisions of the residual left pocket the patient was referred to our hospital. We decided to perform full extraction of all the leads and the device (increased C-reactive protein and blood samples positive for S. epidermidis). The procedure was carried out under conscious sedation in a hybrid-room with an active surgical back-up. After heavy debriding we obtained only few centimeters of the abandoned right-ventricular (RV) lead. However, it was enough to advance a locking stylet (LLD, Spectranetics Corporation, Colorado Springs, USA) to the lead tip. Manual traction was ineffective and a 14F laser-sheath (Spectranetics Corporation, Colorado Springs, USA) was advanced until the space between the clavicle and the first rib. Thereafter it was not possible to further advance the sheath, but a new attempt of manual traction was effective in freeing the right ventricular lead (Fig. 1-A). However, the left superior route proved to be ineffective for reaching the intravascular atrial lead. Considering the closeness of the proximal-edge of the atrial lead to the area which prevented laser sheath advancement, we feared that the same heavy adhesions could prevent percutaneous lead extraction by any approach. We advanced a medium curl 7F ablation catheter into the right atrium through an 18F femoral introducer and after many attempts, we were able to border the atrial lead (Fig. 1-B). In the meantime a 20-snare (Andrasnare: Andramed GmbH, Reutlingen, Germany) was advanced through a second femoral introducer to reach the tip of the ablation catheter and stabilize it (Fig. 1-C,D). A combined traction of both the ablation catheter and the snare (i.e. respectively the “stick” and “rope” of the title) was able to free both the proximal portion of the atrial lead and the distal end of the more recently implanted RV lead (Fig. 2-E). The RV lead was then effortlessly extracted from the subclavian access. Instead, the atrial lead appeared heavily trapped inside the atrial appendage. In order to avoid an atrial tear by insisting with simple traction we stabilized the lead with the first 20-snare while the 14F laser sheath was advanced into the inferior vena cava through a femoral introducer with a second 20-snare inside, which was used to secure the terminal part of the broken lead (Fig. 2-F). The laser sheath was then advanced over the secured lead up to the right atrial appendage while the first snare was maintained loosely around the system as a safety measure (“safety snare”). After few further laser bursts the outer insulation of the lead suddenly broke and came out of the sheath leaving the inner conductor, connected to the tip of the lead, exposed inside the laser sheath (Fig. 2-G). The presence of the “safety snare” allowed to stabilize once more the remaining part of the lead which was again reached by the second snare inside the 14F laser sheath permitting to free it in few further laser burst (Fig. 2-H). In view of the pacemaker-dependency and the double sub-clavicle access we implanted an epicardial pacemaker via sub-xyphoid route. Fig. 2After stabilizing the ablation catheter (arrow 5) with the snare (arrow 6), a combined traction was effective in freeing both the proximal portion of the atrial lead (arrow 3) and the terminal portion of the last RV lead (arrow 4, the screw mechanism was jammed). In the meantime a bipolar catheter (arrow 7) was advanced into the RV in view of pacemaker dependency of the patient (Panel E). After ineffective traction of the atrial lead by the snare, the laser sheath was advanced over a second snare (arrow 8) through the 18F femoral introducer (arrow 9) (Panel F). After reaching the tip of the atrial lead we delivered laser bursts with caution, the first snare was advanced outside the laser sheath as a safety measure (the “safety snare”, arrow 6). However, the outer insulation suddenly broke after few laser bursts leaving the inner conductor alone (panel G) inside the laser sheath (3a tip of atrial lead, 3b exposed inner conductor, 3c outer insulation). The “safety snare” was used to stabilize the inner conductor that was then reached with the second snare after completely removing the insulation. Few laser bursts were effective in freeing the tip of the atrial lead (3a, panel H). View Large Image Figure Viewer Download Hi-res image