Transvenous Approach Research Articles

N-butyl cyanoacrylate transvenous arteriovenous malformation embolization with arterial balloon assistance: Defining parameters for a transvenous approach as a potential upfront treatment option in managing cerebral arteriovenous malformations

Complete obliteration of arteriovenous malformations (AVMs) using a transvenous approach as the primary and stand-alone treatment modality has been increasingly considered as a useful endovascular approach in the treatment of AVMs. AVMs are typically treated with microsurgery, stereotactic radiosurgery, endovascular embolization, or some combination of the three methods. Preservation of the draining vein is a key requisite common to all treatment modalities. Transvenous embolization (TVE) is conventionally not recommended as a stand-alone treatment for the vast majority of AVMs and has been thought to be best indicated when traditional approaches are considered less safe and when specific evaluation criteria are met. We report a case of a 35-year-old asymptomatic male diagnosed with a small intracranial AVM adjacent to the right motor strip which was managed utilizing this approach. We employed endovascular embolization via a transvenous approach with arterial balloon assistance due to the small size of the nidus, eloquent location, en passage arterial supply proximal to the venous varix, and a single draining vein from the fistula. This case illustrates the selective indications and technical nuances of TVE approach in managing AVMs as a potential upfront treatment option. When patients harbor AVMs with specific angio-architectural findings as outlined, TVE utilizing Onyx or N-butyl cyanoacrylate can be safely performed as a primary treatment modality.

Guidelines on the use of liver biopsy in clinical practice from the British Society of Gastroenterology, the Royal College of Radiologists and the Royal College of Pathology

Liver biopsy is required when clinically important information about the diagnosis, prognosis or management of a patient cannot be obtained by safer means, or for research purposes. There are several...

A minimally invasive approach for the treatment of isolated type intracranial dural arteriovenous fistula in a neurosurgical hybrid operating room

ObjectivesIsolated-type intracranial dural arteriovenous fistulas (DAVFs) could hinder the effective use of the transvenous approach. Direct trans-sinus embolization (dTSE) with craniotomy remains the treatment method for isolated-type DAVFs. We report our experience in using a neurosurgical hybrid operating room (NHOR) to treat cases of isolated-type DAVFs by dTSE using a single burr hole. Patients and methodsBetween April 2007 and March 2017, 189 DAVFs were treated by an endovascular procedure at our institution. Among these cases, 27 patients (14.3%) had isolated-type DAVF and 7 patients (3.7%) were treated by dTSE. The procedure accuracy and invasiveness of dTSE were compared with those of the transvenous embolization (TVE) group.The NHOR was equipped with a biplane angiography system and used to perform 3D rotational angiography (3DRA). The burr hole site was precisely determined by 3DRA. Only one burr hole was made to expose the target sinus and allow for direct puncture. The target sinus was occluded by using coils and liquid embolic material. ResultsThe NHOR allowed the accurate placement of the burr hole. Only a single burr hole and small skin incision (with minimal bleeding) were required for each dTSE case. The mean total contrast volume was significantly reduced in the dTSE group compared with that in the TVE group. Moreover, the dTSE group required shorter operation times and lower total radiation doses compared with the TVE group. ConclusionUsing dTSE could be performed with a single burr hole using a NHOR equipped with biplanar fluoroscopy. This approach is a minimally invasive and effective treatment for isolated-type DAVFs.

Embolization of carotid-cavernous fistulas: A technical note on simultaneous balloon protection of the internal carotid artery

A carotid-cavernous fistula (CCF) is an abnormal connection between the carotid circulation and the cavernous sinus. Treatment of CCFs often consists of obliteration of the fistula by a transarterial or transvenous endovascular approach using embolic agents. However, fistula embolization is often halted due to the potential embolic complications that may arise from the retrograde flow of the embolic agents into the arterial circulation, which often leads to the development of fistula recurrence. Moreover, retreatment of a CCF recurrence is challenging and more complex approaches may be required. In this technical note, we describe our experience with CCF embolization in 25 patients treated at a single center. We utilized a transvenous approach for CCF embolization with simultaneous balloon occlusion of the internal carotid artery during the infusion of the embolic material into the fistula. In our series, this simultaneous protection of the internal carotid artery showed to be a safe technique to prevent embolic complications and to achieve successful obliteration of the fistula. On follow-up, 2 cases presented a recurrence, one due to technical difficulties and the other related to an undetected vascular injury. In conclusion, this technique provides a safe approach in the treatment of CCFs by decreasing the risk of embolic complications and increasing the effectiveness of the embolic agents in accomplishing the obliteration of the CCF.

Two Cases of Cardiac Implantable Electronic Device Placement via Persistent Left Superior Vena Cava.

Persistent left superior vena cava (PLSVC) is the most common variation of anomalous venous return to the heart and present in 0.1–0.5% of the general population. The left anterior cardinal veins typically obliterate during early cardiac development but failure of involution results in PLSVC. It is an asymptomatic congenital anomaly, usually discovered while performing interventions through the left subclavian vein or during cardiovascular imaging. PLSVC can be associated with cardiac arrhythmias and congenital heart disease. We present two cases of PLSVC: first, a 68-year-old male who presented with complete heart block, for which a temporary pacemaker was initially inserted followed by a permanent pacemaker; second, a 53-year-old female with a history of hypertension and ischemic cardiomyopathy with a left ventricular ejection fraction of 25%, and a survivor of sudden cardiac death, who underwent an implantable cardioverter-defibrillator (ICD) for secondary prevention.Both cases of PLSVC were detected incidentally during the transvenous approach to the heart. PLSVC was suspected by the unusually left medial position of the lead, while cineflouroscopy showed the venous trajectory toward the coronary sinus and drainage into the right atrium. It is technically difficult to cross the wire through the tricuspid valve when coming from the PLSVC and coronary sinus without making a loop in the right atrium, which is known as a wide loop technique.PLSVC is an uncommon anomalous anatomical variant and should be recognized appropriately by specialists who frequently carry out procedures through the left subclavian vein, such as implantation of permanent pacemaker, ICD and cardiac resynchronization therapy. It should also be recognized that wide loop formation of the right ventricular lead in the right atrium is helpful to cross the tricuspid valve and to affix the lead in the right ventricle.LEARNING POINTSPersistent left superior vena cava is an anatomical variant that should be recognized by specialists who frequently carry procedures through the left subclavian vein (e.g. implantation of a permanent pacemaker, implantable cardioverter-defibrillator and cardiac resynchronization therapy).Maneuvers like wide loop formation of the right ventricular lead in the right atrium is helpful to cross the tricuspid valve and to affix the lead in the right ventricle.The cardiac imaging specialist should also suspect and rule out PLSVC on encountering a dilated coronary sinus on any imaging modality

COMPLETE FOUR CHAMBER RESYNCHRONIZATION VIA NOVEL PERCUTANEOUS EPICARDIAL PACING LEAD

The vast majority of pacemaker systems are implanted through the transvenous approach which conveys many potential challenges and complications. The benefits of ventricular resynchronization are well established and there is mounting evidence for the use of atrial resynchronization in heart failure

SURGICAL VERSUS TRANSVENOUS PACING OUTCOMES IN ADULT CONGENITAL HEART DISEASE

Adults with congenital heart disease (ACHD) often require cardiac implantable electronic devices (CIED). To date, there is no data comparing transvenous (TV) or epicardial (EPI) approaches in an exclusively adult population. A retrospective review was performed for all CIED implants at the Ahmanson

Posterior Fossa Dural Arteriovenous Fistulas: Outcomes of endovascular treatment

Introduction Dural Arterio-Venous Fistulas (dAVF) located in the posterior fossa are a rare entity. Objectives of the study were to analyze the anatomy of the dAVF, their endovascular treatment strategies and clinical outcomes. Methods Two centers retrospectively selected patients treated between January 2009 and June 2018 for posterior fossa dAVF. We collected patient demographics, clinical presentation, arterial and venous outflow anatomy of the dAVF and treatment outcomes. Results Twenty-six patients treated endovascularly for posterior fossa dAVF type III, IV or V, have been included. 100% of the dAVF were occluded: transarterial approach was performed in 23 dAVF (88.5%), combined transarterial and transvenous approach for 2 dAVF (7.7%) and transvenous approach alone for 1 dAVF (3.8%). Middle meningeal artery (MMA) was the most common artery chosen to inject embolic liquid (46%, 12/26). Procedure related morbidity was 15.4% at 24 hours, 7.7% at discharge and 0% 6 months. Procedure related mortality was 0%. Conclusion Endovascular treatment offers high occlusion rates for posterior fossa dAVF with low morbi-mortality rates. Arterial approach is the first line preferred approach even if transvenous or combined approach can be a safe and effective option for patients with favorable anatomy.

Abstract No. 682 Updates for extremity arteriovenous malformations involving the bone: approach for embolization and its therapeutic outcomes

To evaluate long-term data of the therapeutic outcomes, complications of embolotherapy retrospectively and establish therapeutic approach of embolotherapy of extremity arteriovenous malformations (AVMs) involving the bone. From December 1996 to July 2019, 36 patients (18 male, 18 female; mean age 25.1; age range, 1–64 years) with extremity AVMs involving the bone underwent staged embolotherapy using ethanol, coils and NBCA (n-butyl cyanoacrylate). Nineteen patients had pure bone AVMs and 17 had mixed bone and soft-tissue AVMs. Embolotherapy was performed by direct puncture, transvenous, and intraarterial approach (range, 1–18 procedures; mean, 4.9 procedures). Therapeutic outcomes were established by evaluation of the clinical response of symptoms and signs, as well as the degree of devascularization at follow-up angiography or computed tomography. Major and minor complications were also investigated during the follow-up at vascular malformation clinic. The clinical success (combined cure and markedly improvement outcomes) rate of embolotherapy of pure bone AVM was significantly better than that of mixed bone and soft tissue AVM (84.2% vs. 17.6%, P <0.001). Complete devascularization rate of bone AVM component of mixed bone and soft tissue AVM was 70.6%, but cure rate of mixed bone and soft tissue AVM was 0% because of skin and subcutaneous involvement of AVM. Twelve patients (11 minor; skin and transient peripheral nerve injury, 1 major; longstanding nerve palsy) experienced complications. The difference of complication rate between pure bone AVM and mixed bone and soft tissue AVM was not statistically significant (42.1% vs. 23.5%, P = 0.409). Embolotherapy of extremity AVMs involving the bone is effective and safe treatment to eliminate or improve symptoms with long-term follow-up data, especially in pure bone AVM.

Treatment of low flow, indirect cavernous sinus dural arteriovenous fistulas with external manual carotid compression – the UK experience

Introduction: External manual carotid compression (EMCC) is a treatment option for indirect cavernous sinus dural arteriovenous fistulas (CS-DAVF). The exact mechanism of how this works is unclear but compression of the carotid and jugular produces thrombus in the cavernous sinus (CS). Although compression of the superior ophthalmic vein (SOV) has been described as a treatment option this technique is not always amenable. We studied the clinical features, imaging studies, complications and resolution of CS-DAVF in a series seven patients.Materials and methods: Between 2011 and 2017 we treated 7 patients (4 female, 3 male, age range: 60–86 years) with EMCC for an indirect, low-flow CS-DAVF (Barrow B-D). Patients compressed the cervical carotid artery on the side of the CS-DAVF using the contralateral hand for 5–10 seconds 5–10 times per day. Using gradually increasing pressure they compressed the carotid artery and jugular vein until the pulse was no longer palpable.Results: 6 patients had complete resolution of their CS-DAVF within a range of 5–24 months of symptom onset (median 8 months). 5 of our patients had complete resolution of their clinical symptoms at final follow-up. One patient had a failed endovascular procedure, and subsequently underwent surgery to cannulate the SOV for a transvenous endovascular approach to the fistula but in the meantime she had performed EMCC, which is thought to have resolved the fistula. One patient remains under follow-up and is performing EMCC.Conclusion: EMCC is a safe and low risk technique for low-flow indirect CS-DAVF and should be considered as a first line treatment for patients unable to have endovascular treatment. Although compression of the SOV has been described this can often be difficult to perform in the context of periorbital oedema. EMCC should always be performed using the contralateral hand, because this will ensure that the compressing hand falls away should cerebral ischaemia develop.:

Advances in Pediatric Ductal Intervention: an Open or Shut Case?

To review the most recent literature on pediatric transcatheter ductal intervention including ductus arteriosus occlusion and stenting. With the development and FDA approval of smaller ductal devices, including most recently the Amplatzer Piccolo Occluder (Abbott, Abbott Park, IL), transcatheter ductus arteriosus device closure is now being safely performed in premature infants and patients < 6kg using a transvenous approach. In patients with ductus-dependent pulmonary blood flow, ductal stenting with pre-mounted coronary artery stents has been shown to be an acceptable alternative to the surgically placed Blalock-Taussig shunt. Centers with experience in ductal stenting have demonstrated success, even with the tortuous ductus. Innovation in transcatheter device technology and procedural practices have allowed for significant advances. Transcatheter ductal device closure is a reasonable alternative to surgical ligation even in premature, low-birthweight infants. Ductal stenting is also an accepted alternative to the modified Blalock-Taussig shunt. We anticipate continued advancement and procedural refinement over the next several years.

Ethmoidal dural arteriovenous fistulas: endovascular transvenous embolization technique

Ethmoidal dural arteriovenous fistulas (dAVFs) are rare, accounting for 1–1.5% of all intracranial malformations. However, they may have angiographic features that increase the risk of rupture: cortical venous drainage, venous...

Transvenous management of cardiac implantable electronic device late lead perforation.

Late lead perforation (LLP), defined as perforation ≥30 days from cardiac implantable electronic device implant, is a rare diagnosis and little data exist regarding management practices and outcomes. The purpose of this study was to evaluate the occurrence, safety, and efficacy of transvenous management of clinically significant LLP. The electronic medical records of a single-center tertiary hospital were reviewed for all patients who were referred for LLP or its sequelae. Eleven consecutive patients were identified from October 2011 to December 2018 with clinically significant LLP. Patients most often presented with pericardial symptoms with the exception of one asymptomatic patient. The median time from lead implant to intervention for LLP was 246 days. Nine patients were managed with an initial transvenous approach, with one requiring sternotomy (lead 6.3 years old). Two patients had a surgical approach, one performed at an outside hospital with subsequent death and another had a mini-thoracotomy, but the lead was removed percutaneously with no surgical repair. In this small cohort, there was no association between the lead extending beyond the parietal pericardium and surgical repair (P = .99). Our single-center experience suggests that LLP can be initially managed with a cautious transvenous approach in most patients, but intraprocedural ultrasound for pericardial monitoring and a rescue plan with immediate surgical back up is mandatory.

Outcomes of transvenous lead extraction in patients with lead perforation: A single-center experience.

BackgroundManagement of cardiac perforation caused by the lead of a cardiac implantable electronic device (CIED) is currently unclear. This study evaluated the outcomes of transvenous lead extraction (TLE) in patients with cardiac perforation caused by a transvenous lead.HypothesisRemoval of perforated lead by transvenous approach is safe and effective.MethodsThe medical records of all patients diagnosed with cardiac perforation by a pacing or defibrillator lead in Peking University People's Hospital from January 2008 to January 2019 were reviewed. We included patients who were managed by TLE.ResultsA total of 53 patients (30 men; mean age: 67 ± 15 years) with lead perforation managed by TLE were included. Most of the perforated leads (94.9%) were pacemaker leads. Forty‐three leads (81.1%) were implanted within 1 year. Ten patients with a high risk of hemopericardium underwent percutaneous subxiphoid pericardial puncture prior to TLE. All 53 culprit leads were removed completely without major complications. Simple traction with or without a locking stylet was sufficient in 51 patients (96.2%). Forty‐eight patients (90.6%) had a new active‐fixation lead reimplanted. No patients showed evidence of new‐onset or worsening pericardial effusion during the procedure and hospital stay. During a median follow‐up time of 16 months, no recurrence of symptoms associated with lead perforation or CIED‐related infection were reported.ConclusionIn most patients with lead perforation, TLE can be a safe and effective management approach.

Outcomes of endovascular procedures in salvage of arteriovenous fistulas via the transradial route: A prospective study

Aim: To evaluate the primary patency and predictors of technical failure of arteriovenous fistulae (AVF) following transradial percutaneous transluminal angioplasty (PTA). Materials and Methods: This was a prospective study being conducted to evaluate the primary patency and predictors of technical failure of AVF following transradial PTA. This will help us identify high-risk patients and plan interventions in them at an earlier time to avoid access loss. The time period of the study was from October 2016 to October 2018 in the Department of Vascular and Endovascular Surgery at Sri Ramachandra Medical College, Chennai, Tamil Nadu. A total of 44 patients were included in this cohort and they were all followed up in the outpatient department and via telephonic contact for a period of 1 year. All the patients who underwent endovascular AVF salvage fitting the inclusion criteria were included in the study. The demographics of the patients were recorded at admission and patients were investigated for the cause of fistula dysfunction at the treating physicians discretion and an ultrasound Doppler was ordered for all patients to ascertain the cause of the stenosis. The statistical analysis was done by the ANOVA and t-test. Results: A total of 44 patients were included in this cohort and they were all followed up for a period of 1 year. The 30-day, 90-day, 6-month, and 12-month primary patencies were 84.1%, 81.8%, 63.63%, and 43.18%, respectively. Our technical success was 88.6%. In our study, we found that longer lesion lengths (>4 cm) were prone to early loss of primary patency and this was statistically significant. We found that patients above 60 years of age had lower primary patencies and the presence of diabetes mellitus also lowered the primary patency. Fistula maturation age did not show a correlation with patency in our cohort. Male patients had a higher patency rate and juxta-anastomotic stenoses postangioplasty had a higher primary patency due to the shorter lengths. Radiocephalic fistula angioplasties had a higher patency as compared to brachiocephalic angioplasty. Conclusion: Ours is the first study in India to proactively and preferably use the transradial approach over the transvenous approach, as it confers many benefits. The challenges of the transradial route are the smaller size of the radial artery in the Indian population as compared to the western population.

Transvenous arteriovenous malformation embolization

Transvenous embolization of arteriovenous malformations has emerged as a safe and effective intervention. In carefully selected patients the transvenous approach has shown efficacy similar to that of conventional transarterial routes....

Multimodal Management of Carotid-Cavernous Fistulas

Techniques for endovascular management of carotid-cavernous fistulas (CCFs) have evolved over the years. Current strategies include transarterial or transvenous approaches and direct puncture or exposure of the cavernous sinus. Rarely, complex CCFs may require multiple approaches or procedures. We describe our experience managing CCFs, reporting on outcomes and technical nuances. A retrospective review of institutional records was conducted to identify consecutive cases of CCF treated between July 2005 and July 2016. Pertinent technical details and outcomes were recorded. In 44 patients, 51 procedures were performed. There were 13 direct CCFs and 31 indirect CCFs: 13 (30%) type A, 3 (7%) type B, 5 (11%) type C, and 23 (52%) type D. A transarterial approach was selected in 39% of cases (n= 20), resulting in a long-term successful embolization rate of 60% (n= 12). Transvenous methods via the inferior petrosal sinus or superior ophthalmic vein were used in 49% of cases (n= 25), resulting in a long-term obliteration rate of 88% (n= 22). Multimodal management was required in 5 patients, including 1 patient in whom a craniotomy was performed to facilitate coil embolization of the cavernous sinus under direct vision. A 7% complication rate (n= 3) was observed, with significant morbidity in 1 patient. CCFs are complex vascular lesions that require facility with various endovascular and surgical approaches. High-flow, direct-type fistulas may harbor a significant risk of recurrence after transarterial embolization. Partial or unsuccessful embolization may necessitate an open surgical approach to the superior ophthalmic vein or cavernous sinus.

P4528Feasibility and safety of left bundle branch area pacing by transvenous approach through the interventricular septum in patients with left bundle branch block

Abstract Background His bundle pacing (HBP) has been shown to correct left bundle branch block (LBBB), however it often requires high pacing output and the success rate is variable. Objective To assess the feasibility and safety of left bundle branch area pacing (LBBAP) in patients with LBBB. Methods From Apr 2014 to Aug 2018, patients with LBBB from multicenters indicated for CRT or pacing therapy were included. LBBAP was performed by advancing the MDT 3830 lead deep into the septum about 1 cm distal to the His bundle region (Figure 1F). Pacing characteristics, success rate, threshold and R-wave amplitude were assessed. Results A total of 94 patients aged 68.3±10.7 y with the native QRS duration of 167.2±17.2 ms were included. In 92 patients, LBBAP was successfully achieved and demonstrated RBBB pattern during unipolar tip pacing (UTP), with the paced QRS duration of 116.4±12.6ms (Figure 1C). Fusion of LBBAP and native conduction via the RBB eliminated RBBB and resulted in an average QRS duration of 103.2±10.1 ms (Figure 1D). LBB potential could be recorded from the LBB lead during correction of LBBB by HBP in 21 patients who used two leads method (His lead and LBB lead, Figure 1B). Output dependent selective and non-selective LBBAP were demonstrated in 48 patients (Figure 1C, D). The LBB capture threshold by UTP was 0.53±0.18V/0.5ms at acute and 0.62±0.17V/0.5ms at 6 months and 0.65±0.2V/0.5ms at 1 year. The R-wave amplitude were 11.4±5.2mV, 12.4±5.8mV and 12.0±5.8mV at acute, 6 month and 1 year. During follow-up, only one patient had an increase in LBB capture threshold to 2.5V/0.5ms at 3 months and there were no other complications such as dislodgment, infections, embolism or stroke associated with the implantation. Conclusion Permanent LBBAP is feasible and safe in patients with LBBB.

Acute and Long-Term Outcomes of Transvenous Cardiac Pacing Device Implantation in Patients With Congenital Heart Disease.

Background: Little is known about the acute/long-term outcomes of implantation of cardiac implantable electronic devices (CIED) using a transvenous approach for patients with congenital heart disease (CHD).Methods and Results: We retrospectively investigated the acute/long-term results and complications associated with transvenous CIED implantation in 140 patients with CHD. We implanted 77 pacemakers, 51 implantable cardioverter defibrillators (ICD), and 12 cardiac resynchronization therapy (CRT) devices. Although we successfully implanted pacemakers and ICD in all patients, we could not place a coronary sinus (CS) lead in 25% of the patients requiring CRT devices due to coronary vein anomalies associated with corrected transposition of the great arteries (cTGA). Overall complication rate, lead failure rate, and incidence of device infection were 16%, 9%, and 0.7%, respectively. There was no significant difference in overall complication rates between the simple (n=22) and complex CHD (n=118) groups (14% vs. 16%). The 10-year lead survival for the ICD leads (77%) was significantly lower than for the pacemaker leads (91%, P=0.0065).Conclusions: The outcomes of transvenous CIED in patients with CHD seemed acceptable, although there was a relatively high incidence of complications. CS lead placement for cTGA may be hindered by coronary vein anomalies. Lead survival tended to be lower for ICD than for pacemakers in these patients.

Salvage of Exposed Cardiac Implants Using Fasciocutaneous Rotation Flaps

Implantation rates of cardiac implantable electrophysiological devices (CIEDs) are rising, mainly because of the expansion of implantable cardioverter-defibrillators indications for primary prevention. As the CIED usage increases, CIED-related complications are also in rise. Transvenous approach and laser utilization techniques are replacing the open heart surgeries, for removal of CIED systems that are suspected to be infected. In this study, we aimed to share our new method of fasciocutaneous flap coverage results of patients with exposed CIED systems who were not eligible for the CIED replacement surgery for various reasons. Patients operated with rotational fasciocutaneous flaps with addition of pectoralis fascia, owing to their exposed CIEDs between June 2016 and January 2019, were enlisted. Patients with signs of infection whether systemic or limited to the CIED pocket with or without positive blood cultures were referred to infectious diseases department and not included in this study. Patients included in the study were evaluated retrospectively in terms of demographic data, implanted CIED type, time elapsed from implantation to exposure, from referral to flap coverage operation, total follow-up time, survival ratios during follow-up, and complications related to flap coverage operation. In addition, indications for CIED implantation, patient comorbidities, and culture results obtained from the capsule encompassing the CIED battery unit were included to the evaluation. A total of 13 patients with exposed CIEDs have undergone total capsulectomy and CIED system coverage with rotational fasciocutaneous flaps. The mean patient age ± SD was 60.2 ± 13.4 years. The average time elapsed from CIED implantation to exposure was 27.3 ± 15.4 months. The average time spanned from initial referral to operation was 6 ± 1.6 days. The most prevalent comorbidity was diabetes mellitus. The average time elapsed during operation for pectoral fascia incorporated rotation flaps was 90 ± 10.6 minutes. Coagulase negative staphylococci were the dominant species (46.5%) obtained from capsule cultures. Apart from 1 case of hematoma, no early or late operation-related complication was encountered. A more precise definition of contamination and infection has to be made in guidelines, which may lead the first group to be treated without extraction. Surgical method defined in this study can be used for the treatment of patients in contaminated CIED subgroup, conserving individuals from risks of device extraction.