Use of vacuum-assisted aspiration for removal of vegetations during transvenous lead extraction

Abstract

Transvenous lead extraction (TLE) is recommended for cardiac implantable electronic device infections. While existing literature reports experience using routine TLE for vegetations 2.5 cm.5 Ho and colleagues6 recently reported an 18.5% incidence of lead thrombi, all of which were <2 cm, and there were no immediate complications associated with TLE in these patients. The standard of care for patients with large vegetations on the leads has been to refer patients directly to surgical extraction. There is significant morbidity for the surgical lead extraction compared to patients undergoing TLE.7 It has been noted that there is a significant increase in risk of stroke with the presence of cardiac implantable electronic device leads8; therefore the risk of stroke is likely higher with TLE in patients who have patent foramen ovale or an atrial septal defect. In patients without cardiac implantable electronic devices, isolated right-sided endocarditis constitutes 5%–10% of all cases of endocarditis.9 Among these, approximately 20% require surgical intervention. Similarly, there are limited data for the management of active infections.10 Percutaneous options for treatment of large right-sided vegetations may now be available. Numerous reports have demonstrated the use of the AngioVac™ system (AngioDynamics Inc, Latham, NY) to debulk and remove vegetations and thrombi prior to and/or during TLE.11 However, multiple concerns remain about the use of this system in a critically ill patient with high operative morbidities, including portability, vascular complications, size of cannulas for the system, need for system anticoagulation, difficulty steering the catheter, and cost of acquiring/maintaining the system. The Indigo™ Thrombectomy System (Penumbra, Inc, Alameda, CA) is an aspiration catheter designed to engage the clot and extract it with a continuous vacuum pump. Key Teaching Points • The Indigo™ Thrombectomy System (Penumbra, Inc, Alameda, CA) can safely be used for extraction of right-sided lead-associated vegetations. • Intracardiac echocardiography in the right atrium in conjunction with vacuum-assisted vegetation removal can give the electrophysiologist better anatomical views of vital structures and improved success with vegetation extraction. • Vegetation removal can be safely performed without anticoagulation.