Laser Sheath Research Articles

Transvenous extraction of conduction system and lumenless pacing leads.

Conduction system pacing (CSP), often accomplished with lumenless pacing leads, is increasingly employed to achieve physiologic ventricular activation. There are limited data on the extraction of these leads. The objective of this study was to describe the safety and efficacy of extraction of CSP pacing leads and compare outcomes with extraction of non-CSP lumenless leads. Patients undergoing CSP/non-CSP lumenless lead removal were included. Outcomes of interest included rates of complete procedural success, complications, and successful reimplantation. Overall, 23 patients were included (n = 14 with CSP and n = 9 with non-CSP lumenless leads implanted in the right atrium, right ventricle, or septum). The mean age was 52.7 ± 24.0 years, 30% were female, and the mean lead age was 4.5 ± 4.4 years. The complete procedural success rate was 100%. One serious complication occurred in the non-CSP group but was unrelated to the lead of interest. Manual traction alone was successful in 57% of CSP cases (mean lead age 2.4 ± 1.7 years) and in 11% of non-CSP cases (mean lead age 7.9 ± 5.3 years). Laser sheaths were used in 43% of CSP cases and 89% of non-CSP cases; rotational cutting tools were used in no CSP cases and in 33% of non-CSP cases. Reimplantation in the conduction system was attempted with a left bundle branch pacing lead and successful in 80% (n = 4/5). Extraction of CSP and non-CSP lumenless leads is feasible with a high success rate and a good safety profile. CSP reimplantation after extraction is also feasible with good electrical performance.

Transvenous extraction and reimplantation procedures for quadripolar left ventricular leads with an active fixation side helix.

Five ASQ extraction cases from our hospital were showed in this list. All leads were completely removed and there were no serious complications. Laser sheaths were used in four of the five cases. In cases 2 and 4, LV leads were successfully reimplanted after the removal of the ASQ, and the original target branches where the ASQ had been implanted remained patent.

Outcome of transvenous lead extraction in nonagenarians: A single-center retrospective study.

Transvenous lead extraction (TLE) for cardiovascular implantable electronic device (CIED)-related infections has increased. The incidence of TLE in nonagenarians is low, with limited reports outlining the outcomes of this procedure. Therefore, in this study, we aimed to clarify the outcomes of TLE in nonagenarians. Patients with TLE treated at our hospital between 2014 and 2023 were retrospectively examined; patient characteristics, device type, indications, procedures, complications, and clinical data of nonagenarians were analyzed. Of 12 patients with 24 leads (active fixation lead, n=11; passive fixation lead, n=13) who underwent TLE, the indication for TLE was infection (pocket infection, n=8; sepsis, n=4). Methicillin-resistant Staphylococcus epidermidis was the most frequently identified causative agent (n=4). The median patient age was 91 years; five patients were female. The median lead dwell time was 9 years. Excimer laser sheath (16 leads), mechanical sheath (five leads), Evolution RL (one lead), and manual traction (two leads) were employed in TLE. The procedure was successful in all patients, and only one had a minor complication. Six patients required CIED re-implantation, and leadless pacemakers were selected for five patients. The 30-day mortality after TLE was 0%. TLE can be safely performed in nonagenarians. The decision to perform TLE should not be based on old age alone; the suitability of removing infected CIEDs should be determined based on each patient's condition.

Computed tomography predictors of increased transvenous lead extraction difficulty.

The ability of computed tomography (CT) characteristics to predict the difficulty of transvenous lead extraction (TLE) is an evolving subject. To identify CT characteristics associated with increased TLE difficulty. All consecutive patients undergoing TLE at the University of California San Diego from January 2018 to February 2022 were analyzed, utilizing the UC San Diego Lead Extraction Registry. Patients underwent cardiac-gated chest CT scans with intravenous contrast; all scans were reviewed by a single radiologist. Lead extraction was performed per standard institutional protocol with the initial use of a laser sheath and crossover to a mechanical sheath as needed. Multivariable linear and logistic regression analyses were performed to identify predictors of individual lead-removal fluoroscopy time and mechanical sheath use, as markers of extraction difficulty. A total of 343 patients were analyzed. The mean age of the study population was 63.8±15.4 years; 71% were male. The mean lead dwell-in duration was 8.6±5.7 years. In multivariable linear regression analysis, venous occlusion detected on CT was independently associated with higher individual lead-removal fluoroscopy time (p=0.004), when adjusting for clinical characteristics such as lead dwell time. In multivariable logistic regression analysis, calcification and venous occlusion were independently associated with a higher need for mechanical sheath use during TLE (odds ratio:5.08, p<0.001, 95% CI: 2.54-10.46) and (odds ratio:3.72, p<0.001, 95% CI: 1.89-7.35), respectively. In patients undergoing TLE, venous occlusion identified by chest CT is associated with increased fluoroscopy time. Patients with lead-associated calcification or venous occlusion detected by chest CT are each five and three times more likely to require crossover from laser to a mechanical sheath.

Procedural outcome of transvenous lead extraction in patients with right-sided leads - a GALLERY subgroup analysis

Abstract Background Transvenous lead extraction (TLE) in patients with cardiac implantable electronic devices has become a well-established therapy for patients with lead complications. However, there is limited information on specific outcomes for patients with right-sided leads compared to patients with left-sided leads undergoing TLE. Aim The aim of this study was to analyze patient characteristics, procedural outcomes as well as adverse events and mortality of patients with right-sided leads undergoing TLE with the excimer laser sheath as a first line therapy. Methods We performed a subgroup analysis of all reported patients in the GALLERY (GermAn Laser Lead Extraction RegistrY) with unilateral right-sided leads (Group 1) or unilateral left-sided leads (Group 2). Results 2438 patients with unilateral leads were analyzed. 750 patients were in Group 1 and 1688 patients were in Group 2. Patients in Group 1 were older (71.1 ± 13.9 vs. 66.5 ± 13.6; p &amp;lt; 0.001), more patients were female (31.7% vs. 22.1%, p &amp;lt; 0.001), had a lower body-mass-index (26.8 ± 4.5 vs. 27.2 ± 4.7; p=0.03) and more patients were pacemaker dependent (44.9% vs. 25.4%, p&amp;lt; 0.001). The primary indication for TLE was local infection (46.0% vs. 30.6%, p&amp;lt; 0.001) in Group 1 and lead dysfunction (20.0% vs. 36.1%, p&amp;lt; 0.0001) in Group 2. The frequency of TLE for systemic infection was indifferent between groups (28.9% vs. 27.6%, p=0.532). The most common device to be extracted were pacemakers (80.1% vs. 22.7%, p&amp;lt; 0.001) in Group 1 and implantable cardioverter-defibrillators (ICD) (9.7 vs. 45.3%, p&amp;lt; 0.001) and cardiac resynchronization therapy devices (CRT) (9.6 vs. 31.5%); p&amp;lt; 0.001) in Group 2. The mean number of total leads was not different between groups (2.4 ± 0.9 for Group 1 vs. 2.3 ± 1.0 for Group 2; p=0.98), however median lead dwell time (120 vs. 85 months, p&amp;lt; 0.001), patients with abandoned leads (32.0% vs. 25.9%; p=0.0022) and the use of additional extraction tools (8.4% vs. 5.7%, p=0.016) were significantly higher in Group 1. Patients with right-sided leads had a longer median hospital stay (10 vs. 9 [5; 15] p=0.001). Complete procedural success was higher in patients Group 2 (89.1 vs. 93.1%, p=0.001) but there was no difference in clinical success rates (97.7% vs. 98.0%, p=0.74). There was no difference in overall complication rates (4.3% vs. 4.2%, p=0.945). Neither procedure related mortality (0.3% vs. 0.7%, p=0.2940) nor all-cause mortality (3.5% vs. 3.4%, p=0.9101) differed between groups. Conclusion TLE procedures in patients with right-sided leads showed a lower procedural success rate and a higher need of additional tools. This patient group was older, more often pacemaker dependent and had a higher number of abandoned leads. Despite different patient and lead characteristics, there were no differences in clinical success-rates, procedure related complications or all-cause mortality between groups.

Stepwise Approach for Transvenous Lead Extraction in a Large Single Centre Cohort.

Infection, lead dysfunction and system upgrades are all reasons that transvenous lead extraction is being performed more frequently. Many centres focus on a single method for lead extraction, which can lead to either lower success rates or higher rates of major complications. We report our experience with a systematic approach from a less invasive to a more invasive strategy without the use of laser sheaths. Consecutive extraction procedures performed over a period of seven years in our electrophysiology laboratory were included. We performed a stepwise approach with careful traction, lead locking stylets (LLD), mechanical non-powered dilator sheaths, mechanical powered sheaths and, if needed, femoral snares. In 463 patients (age 69.9 ± 12.3, 31.3% female) a total of 780 leads (244 ICD leads) with a mean lead dwelling time of 5.4 ± 4.9 years were identified for extraction. Success rates for simple traction, LLD, mechanical non-powered sheaths and mechanical powered sheaths were 31.5%, 42.7%, 84.1% and 92.6%, respectively. A snare was used for 40 cases (as the primary approach for 38 as the lead structure was not intact and stepwise approach was not feasible) and was successful for 36 leads (90.0% success rate). Total success rate was 93.1%, clinical success rate was 94.1%. Rate for procedural failure was 1.1%. Success for less invasive steps and overall success for extraction was associated with shorter lead dwelling time (p < 0.001). Major procedure associated complications occurred in two patients (0.4%), including one death (0.2%). A total of 36 minor procedure-associated complications occurred in 30 patients (6.5%). Pocket hematoma correlated significantly with uninterrupted dual antiplatelet therapy (p = 0.001). Pericardial effusion without need for intervention was associated with long lead dwelling time (p = 0.01) and uninterrupted acetylsalicylic acid (p < 0.05). A stepwise approach with a progressive invasive strategy is effective and safe for transvenous lead extraction.

Abstract 13072: Safety and Efficacy of Lead Extraction at Time of Device Upgrade

Introduction: Patients with permanent pacemakers may require upgrade to ICD or CRT but there is no consensus on whether unused leads should be abandoned or extracted. Transvenous lead extraction (TLE) adds potential risk and can be complex in cases of complete venous occlusion. The safety and efficacy of TLE as a strategy to upgrade pacemakers has not been systematically explored and the impact of venous occlusion is unknown. Aims: 1) Characterize the success and safety of TLE for the indication of pacemaker upgrade to ICD or CRT 2) Assess the effect of complete venous occlusion on outcomes Methods: A total of 50 patients underwent TLE for the sole indication of pacemaker upgrade at UCSD from January 2018 to January 2023. All patients completed preoperative cardiac TLE CT. In-hospital outcomes and procedural variables were collected by chart review. Association with venous occlusion was analyzed using McNemar and t-tests. Results: All 50/50 (100%) patients had successful TLE and successful device upgrade with CRT-D in 44/50 (88%) patients and DC-ICD in 6/50 (12%) patients. No complications occurred (conversion to open extraction, injury, tamponade). Preoperative CT showed complete venous occlusion in 14/50 (28.0%) patients. Median lead extraction fluoroscopy time was 6.0 minutes (IQR: 3.7-8.5). Laser extraction was required in 48/50 patients (96%), laser sheath upsizing in 4/50 (8.0%), conversion to mechanical sheath in 7/50 (14.0%), and telescoping sheaths in 1/50 (2.0%). Venous occlusion was not associated with different baseline characteristics, TLE techniques, or fluoroscopy time (Table 1). Conclusions: TLE in combination with pacemaker upgrade had excellent procedural success. Preoperative CT identified complete venous occlusion in 28% of patients, but this was not associated with technical difficulty, procedural success, or clinical outcomes. Further studies are required to assess the long-term impact of this lead management strategy.

Comparison of non-laser and laser transvenous lead extraction: a systematic review and meta-analysis.

Transvenous lead extraction (TLE) is performed using non-laser and laser techniques with overall high efficacy and safety. Variation in outcomes between the two approaches does exist with limited comparative evidence in the literature. We sought to compare non-laser and laser TLE in a meta-analysis. We searched Medline, Embase, Scopus, ClinicalTrials.gov, and CENTRAL databases for TLE studies published between 1991 and 2021. From the included 68 studies, safety and efficacy data were carefully evaluated and extracted. Aggregated cases of outcomes were used to calculate odds ratio (OR), and pooled rates were synthesized from eligible studies to compare non-laser and laser techniques. Subgroup comparison of rotational tool and laser extraction was also performed. Non-laser in comparison with laser had lower procedural mortality (pooled rate 0% vs. 0.1%, P < 0.01), major complications (pooled rate 0.7% vs. 1.7%, P < 0.01), and superior vena cava (SVC) injury (pooled rate 0% vs. 0.5%, P < 0.001), with higher complete success (pooled rate 96.5% vs. 93.8%, P < 0.01). Non-laser comparatively to laser was more likely to achieve clinical [OR 2.16 (1.77-2.63), P < 0.01] and complete [OR 1.87 (1.69-2.08), P < 0.01] success, with a lower procedural mortality risk [OR 1.6 (1.02-2.5), P < 0.05]. In the subgroup analysis, rotational tool compared with laser achieved greater complete success (pooled rate 97.4% vs. 95%, P < 0.01) with lower SVC injury (pooled rate 0% vs. 0.7%, P < 0.01). Non-laser TLE is associated with a better safety and efficacy profile when compared with laser methods. There is a greater risk of SVC injury associated with laser sheath extraction.

Octogenarian patients and laser-assisted lead extraction: Should we put a limit?

Transvenous laser lead extraction (TLE) for cardiac implantable electric devices (CIED) is a challenging procedure especially if performed in octogenarians. In this study we evaluated the safety and efficacy of transvenous laser lead extraction in elderly patients. This is a retrospective study of octogenarian patients who underwent laser-assisted lead extraction (LLE) (GlideLight laser sheath, Philips, San Diego, USA). 270 Consecutive patients were included. Patients were divided into two groups. Octogenarian group and non-octogenarian group. The Data was gathered from patients treated between September 2013 and January 2020 and is retrospectively analyzed. Of 270 consecutive patients, 38 (14.0%) were 80 years old or more. The total number of the extracted leads was 556 among which 84(15.0%) from the Octogenarian group. From these leads were 155 single coil leads, 82 dual coil leads, 129 right ventricular pacing leads, 155 right atrial leads, and 35 left ventricular leads. In the Octogenarian group the number of removed leads was as follows: 13 single coil leads, 10 dual coil leads, 28 right ventricular pacing leads, 28 right atrial leads and 5 left ventricular leads. No mortality was recorded in the Octogenarian group. One patient in the YG suffered from a superior vena cava tear and one patient suffered from pulmonary embolism. In octogenarian laser assisted lead extraction patients is a safe and effective procedure. No increase in morbidity, mortality or perioperative complication could be recorded in this group. Age should not be a limiting factor to perform this procedure.

Safety and success of transvenous lead extraction using excimer laser sheaths: a meta-analysis of over 1700 patients.

While numerous studies have demonstrated favourable safety and efficacy of the excimer laser sheath for transvenous lead extraction (TLE) in smaller cohorts, comprehensive large-scale investigations with contemporary data remain scarce. This study aims to evaluate the safety and performance of laser-assisted TLE through a meta-analysis of contemporary data. A systematic literature search was conducted to identify articles that assessed the safety and performance of the spectranetics laser sheath (SLS) II and GlideLight Excimer laser sheaths in TLE procedures between 1 April 2016 and 31 March 2021. Safety outcomes included procedure-related death and major/minor complications. Performance outcomes included procedural and clinical success rates. A random-effects, inverse-variance-weighting meta-analysis was performed to obtain the weighted average of the evaluated outcomes. In total, 17 articles were identified and evaluated, including 1729 patients with 2887 leads. Each patient, on average, had 2.3 ± 0.3 leads with a dwell time of 7.9 ± 3.0 years. The TLE procedural successes rate was 96.8% [1440/1505; 95% CI: (94.9-98.2%)] per patient and 96.3% [1447/1501; 95% CI: (94.8-97.4%)] per lead, and the clinical success rate per patient was 98.3% [989/1010, 95% CI: (97.4-99.0%)]. The procedure-related death rate was 0.08% [7/1729, 95% CI: (0.00%, 0.34%)], with major and minor complication rates of 1.9% [41/1729; 95% CI: (1.2-2.8%)] and 1.9% [58/1729; 95% CI: (0.8-3.6%)], respectively. This meta-analysis demonstrated that excimer laser sheath-assisted TLE has high success and low procedural mortality rates. It provides clinicians with a reliable and valuable resource for extracting indwelling cardiac leads which require advanced extraction techniques.

Associated factors and outcomes of crossover from a laser sheath to a bidirectional rotational mechanical sheath during transvenous lead extraction.

During transvenous lead extraction (TLE), a GlideLight laser sheath (Philips) cannot always be advanced over the lead, and crossover to the Evolution system (i.e., an Evolution RL sheath or Evolution Shortie RL sheath [Cook Medical]) is required. We aimed to determine the associated factors and outcomes of such device crossover. This observational study included 112 patients who underwent TLE. The patients were divided into crossover and non-crossover groups. Outcomes and associated factors of crossover were evaluated. Overall, 57 (50.9%) patients required crossover to the Evolution system (crossover group), whereas 55 (49.1%) patients did not require crossover (non-crossover group). Clinical success rate was similar between the two groups (98.3% vs. 100%; p = 1.00). No major intraprocedural complications related to powered sheaths occurred. Multivariate logistic regression analysis results showed that dwell time of the oldest extracted lead (per year) (odds ratio [OR]: 1.18, 95% confidence interval [CI]: 1.02-1.36; p = .026), number of leads extracted per procedure (OR: 7.23, 95% CI: 1.74-29.99; p = .007), and use of a femoral approach (OR: 21.09, 95% CI: 2.33-190.67; p = .007) were associated factors of crossover. The cutoff for crossover was 7.7 years from the implant (sensitivity 90.5%, specificity 64.9%, area under the curve 0.80). Both groups showed a high rate of clinical success. Switching to the Evolution system may facilitate a safe and effective TLE when a laser sheath does not advance despite laser activation.

Safety of same-day discharge after lead extraction procedures

Same-day discharge (SDD) after cardiovascular procedures is rapidly gaining ground. We sought to evaluate the safety of SDD after transvenous lead extraction (TLE). We performed a retrospective chart review of patients who underwent elective TLE between January 2020 and October 2021 at our institution. The primary outcome was SDD, and major procedural complications and readmissions within 30 days of the procedure were secondary outcomes. In this analysis of 111 patients who underwent elective TLE, 80 patients (72%) were discharged on the same day (SDD group) while 31 patients (28%) stayed overnight (overnight group). Lead malfunction was the most common indication for TLE in both groups. Patients in the overnight group were more likely to have a lead dwell time of ≤10 years than those in the SDD group (38.7% vs 20% of all leads in each group; P = .042), have laser sheaths used for extraction and a higher number of leads extracted. No major complications were reported in both groups. In a multivariate analysis, lower body mass index and the use of laser sheath during TLE were predictors of overnight stay. Patients who underwent a procedure using advanced extraction techniques were 3.5 times more likely to stay overnight (95% confidence interval 1.27-9.78; P=.016). In appropriately selected patients undergoing elective lead extraction, SDD is feasible and safe. Higher body mass index, fewer extracted leads, shorter lead dwell times (<10 years), and less frequent use of laser-powered extraction sheaths were associated with an increased likelihood of SDD.

Thulium fiber laser cystolithotripsy under local anesthesia: A day care procedure.

Bladder stones account for 5% of all urolithiasis. Patients present with LUTS or acute urinary retention. Thus, warranting an early intervention. Minimally invasive approach with laser lithotripsy is the present gold standard to treat bladder stones. To evaluate the outcomes of TFL (60 W) for bladder stones performed under local anesthesia as a day-care procedure. This was a retrospective single-center study conducted after obtaining IRB approval. Study period was between June 2021 and June 2022 were included. All patients were operated under local anesthesia as a day care procedure. The procedure was carried out using an 18 Fr laser sheath and calculus dusted using TFL energy (15-30 W). Parameters including operative time in minutes, complications were recorded. Patients were encouraged oral and normal voiding in the immediate post-op period. A total of 47 patients with bladder stones presented during this period. Of these, 30 underwent laser lithotripsy (TFL) for bladder calculi. The clinical presentation of patients was LUTS in 28 (93%) and 5 (16%) patients had AUR. The average size of the stone in this series was 15 ± 2.8 mm. The mean duration of laser lithotripsy was 15 ± 5.4 min. Energy to dust the stone was variable with mean LASER energy of 18.23 ± 10 W. All patients tolerated the procedure well and none required conversion to conventional anesthesia. One patient failed to void in the post-op period. 100% clearance rate was documented in all patients. Thulium fiber laser for transurethral cystolithotripsy of bladder stones under local anesthesia is a feasible technique with minimal morbidity and good outcome.

Extracción percutánea con vainas mecánicas en las infecciones de dispositivos de electro estimulación cardiaca

The treatment of choice for infections of cardiac pacing devices is currently percutaneous endovascular traction with mechanical or laser dissection sheaths, which in experienced hands has a success rate of almost 98% and a mortality rate of less than 1%.The success of the procedure depends mainly on the experience of the operator and the characteristics of the device itself (pacemaker/defibrillator, side and time of implantation, type, number and condition of the electrodes). Safe extraction with mechanical sheaths requires knowledge of the tools used in the procedure, a systematic approach (including all possible precautions), and a good understanding of the possible complications that may arise. It is also necessary to have the means available for early diagnosis and treatment.Throughout this review we will answer many questions: What to do before we start? How do we perform the extraction? Why use mechanical sheaths and what are their advantages over laser sheaths? Where to start and how to finish?

Rocket-shape crossing technique: A combination of lead extraction and modified venoplasty for device upgrade with venous occlusion.

This case discusses an upgrade method to cardiac resynchronization therapy defibrillator for a 54 year old man with superior vena cava occlusion. Right ventricular lead extraction with modified venoplasty, Rocket shape Crossing Technique (RCT), was performed. In RCT the integration of the inflated balloon, halfway inside the laser sheath, and the laser sheath are advanced through the occlusion like a rocket shape crossing.

High success and safety of transvenous lead extraction using excimer laser sheaths in more than 1700 patients: a meta-analysis

Abstract Funding Acknowledgements Type of funding sources: Private company. Main funding source(s): Philips Background The excimer laser sheath is a commonly used advanced transvenous lead extraction (TLE) tool to aid the successful extraction of indwelling cardiac leads by ablating the tissues adhering to the leads. Many studies have reported favorable safety and efficacy results with leaser sheath assisted TLE in small patient groups. However, to date, there are no comprehensive large-scale studies using contemporary data to analyze the outcomes of excimer laser sheaths assisted TLE. Purpose To assess the performance and safety of excimer laser sheath assisted TLE using meta-analysis of contemporary data. Methods A systematic literature search was performed to identify articles relevant for the evaluation of the safety and performance of the SLS II and GlideLight excimer laser sheaths in TLE procedures from April 1, 2016 to March 31, 2021. Safety outcomes included procedure-related deaths and major and minor complications. Performance outcomes included procedural success and clinical success rates achieved in TLE procedures as defined by 2017 HRS and 2018 EHRA consensus guidelines. A random-effects, inverse-variance-weighting meta-analysis using arsine square root transformation was performed to obtain the weighted average of evaluated outcomes. Results A total of 17 articles were identified and included for evaluation and data extraction, among which 6 were prospective studies and 11 were retrospective studies. The evaluated studies included 1,729 patients with 2,887 leads, among which 311 leads were extracted with the SLS II device, 1,688 were extracted using GlideLight, and the rest (n=888) involved both devices. Overall, 38.5% of leads were extracted due to infection. The most common lead type targeted for extraction were ICDs (47.9%). On average, each patient had 2.3 ± 0.3 leads and the lead dwell time was 7.9 ± 3.0 years. The TLE procedure successes rate per patient was 96.8% (1,440/1,505; 95% CI: [94.9%-98.2%]) and per lead 96.6% (1,447/1,501; 95% CI: [95.1%-97.7%]). The clinical success rate per patient was 98.3% (989/1,010, 95% CI: [97.4%-99.0%]). The weighted average of the procedure-related death rate was 0.08% (7/1,729, 95% CI: [0.00%, 0.34%]), comparable to the mortality rate reported in other studies on lead extraction safety. The most common complications were pericardial effusion or tamponade (n=21), hematoma (n=20) and cardiovascular injuries (n=18). Conclusion TLE utilizing the excimer laser sheath has high success and low mortality rates and provides physicians with a valuable tool for safe and effective extraction of indwelling cardiac leads that require advanced extraction techniques.

Superior vena cava tear during transvenous lead extraction: Medical management in hemodynamically stable patients.

Superior vena cava (SVC) tear is the most lethal complication during transvenous lead extraction (TLE) with a mortality rate as high as 50%. Treatment involves aggressive attempts to maintain cardiac output and immediate sternotomy to localize and repair the vascular tear. Occlusion balloons have been developed to provisionally occlude the lacerated SVC and to provide hemodynamic stability allowing time for surgery. In case of mediastinal hematoma without hemodynamic instability, the strategy remains unclear. We describe two cases of SVC tear during TLE. The first case was a 60-year-old man who presented with a right ventricular single-chamber defibrillator lead fracture and innominate vein stenosis. The RV lead was removed using a laser sheath causing a mediastinal hematoma with no active bleeding during surgical exploration few hours later. The second case was a 28-year-old man that presented with a right atrial (RA) lead fracture and RV lead insulation failure in a dual-chamber defibrillator (ICD). Both the RA and RV leads were removed with mechanical sheaths, and a mediastinal hematoma was medically managed.

PO-02-055 CALCIFICATION AND VENOUS OCCLUSION DETECTED BY COMPUTED TOMOGRAPHY IS ASSOCIATED WITH GREATER NEED FOR MECHANICAL SHEATH UTILIZATION DURING TRANSVENOUS LEAD EXTRACTION

The ideal choice of laser or mechanical sheath use for lead extraction is likely dependent on patient-specific factors. It is unknown whether imaging characteristics detected from cardiac computed tomography (CT) can be used to guide optimal extraction sheath choice. To assess CT characteristics associated with need to upgrade a laser sheath to a mechanical sheath during lead extraction. All consecutive patients undergoing transvenous lead extraction from January 2018 to February 2022 were analyzed, utilizing the UC San Diego Lead Extraction Database. Included patients underwent cardiac-gated chest CT scans with intravenous contrast. All scans were reviewed by a single radiologist to assess presence of calcification and venous occlusion. Lead extraction was performed per standard institutional protocol with initial use of a laser sheath and upgrade to mechanical sheath as needed. Multivariable logistic regression analysis was performed to identify predictors of mechanical sheath use, as a marker of extraction difficulty. A total of 343 patients were retrospectively analyzed. Mean age of the study population was 63.8 ± 15.4 years; 71% were male. Mean lead dwell-in duration was 102.7 ± 68.4 months. In multivariable logistic regression analysis, calcification and venous occlusion were associated with higher need for mechanical sheath use during lead extraction [(odds ratio: 5.3, p <0.001, 95% CI: 2.6-10.8) and (odds ratio: 3.7, p <0.001, 95% CI: 1.9-7.3)], respectively. Patients with calcification or venous occlusion detected by chest CT are each five and three times more likely to require a mechanical sheath during lead extraction.

PO-02-052 COMBINING A LASER SHEATH WITH A ROTATIONAL EXTRACTION SHEATH REDUCES THE ACTIVATION OF THE LASER FOR PERCUTANEOUS LEAD EXTRACTIONS

Transvenous pacemaker or defibrillator lead extractions are high-risk procedures with many strategies for the preferred technique. A frequently fatal complication of this procedure is vessel injury including perforation of the superior vena cava and excessive laser delivery for the lead extraction might cause a fatal injury. To elucidate the advantage of combining a laser with a rotational extraction sheath for aged lead extractions. Three hundred ninety-two consecutive percutaneous lead extraction cases were analyzed. Laser sheaths were used as the first device for percutaneous lead extractions, and after September 2019 an Evolution was used when a laser sheath was not effective in extracting the lead. We compared the laser-only era (L-era: 326 cases) to both the laser and evolution-available era (E-era: 66 cases). The age and male gender were similar between the two groups (L-era vs. E-era: 72.1 vs. 72.9:P=0.9014, 73.9% vs. 62.1%: P=0.0705). The oldest lead age of the patients in the laser-only erawas similar in the Evolution era (L-era 7.9yrs vs. E-era 10.0yrs: P=0.0859). The total procedure time was similar between the two groups (74.4min. vs. 73.1min.: P=0.8659) . Also the complete removal rate was similar between the two groups (96.4% vs. 97.2%: P=0.9301) . On the contrary, the total fluoro time and total laser pulses during the laser-only era were significantly higher than in the Evolution-available era (14.2min. vs. 8.9min; P=0.0001, 967.5 pulses vs. 688.1 pulses; P=0.0295). Major adverse events during extraction procedures occurred in 3 cases (L-era: 0.92%) and none (E-era: 0.0%), but there were no procedure-related deaths in either era. Laser extraction combined with a rotational extraction sheath for percutaneous lead extractions was thought to be a less invasive strategy.

PO-02-056 REAL-TIME VIDEO ASSISTED THORACOSCOPIC SURGERY IN HIGH-RISK TRANSVENOUS LEAD EXTRACTION

Laceration injury to the superior vena cava (SVC) remains the most feared complication of transvenous lead extraction (TLE). Early recognition is crucial to prevent catastrophic complications. Use of real time video assisted thoracoscopic surgery (VATS) during high risk TLE can potentially be useful for prompt recognition of SVC injury. We describe the use of video assisted thorascopic surgery (VATS) guidance for complex transvenous lead extractions (TLE). We conducted a retrospective analysis of all patients that underwent TLE at our institution from September 2018 to November 2022. Our TLE protocol uses a risk stratification scheme of level 1, 2 and 3 based on perceived risk. Defibrillation leads with a dwell time of >10 years or presence of 3 leads with oldest lead >10 years qualify as level 3 TLE cases. All procedures are performed with surgical back up with the use of VAT via a right thoracoscopic approach in level 3 cases. During single lung ventilation, the surgeon places a camera port to provide visualization of the SVC and right atrium for direct visualization during the laser/mechanical sheath manipulation in the great vessels. Out of 41 patients that underwent TLE during the study period, 10 patients underwent concomitant right VATS. Mean age of cohort was 61.5 + 15.2 years and 70% were males. Mean BMI and LVEF was 28.8 + 7.9 & 28.5 + 5.9 % respectively. Indications for TLE included lead malfunction (50%), infection (40%) and removal of abandoned leads in 1 patient. Mean lead dwell time was 10.4 + 5.6 years. Laser sheath was used in all cases with 2 patients requiring use of additional mechanical sheaths. One case demonstrated externalized ICD coil and extraction was abandoned. A femoral approach with snaring was done in 1 patient. All patients had adequate visualization of the SVC via VATS during TLE. Average procedure duration was 134 + 79.1 minutes. There were no immediate procedural complications. VATS port was removed and a chest drain was placed which was removed on post operative day 1 in all patients. VATS allows for direct visualization of the venous structures, provides real time information regarding impending venous injury, and is feasible with minimal impact on procedural risk and length of stay.