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Transvenous lead extraction: The subclavian-to-jugular pull-through technique

Open AccessPublished:December 06, 2022DOI:https://doi.org/10.1016/j.hrcr.2022.12.001

      Keywords

      Introduction

      Transvenous lead extraction is essential in the long-term management of cardiac implantable electronic devices and most procedures are safe and successful.
      • Starck C.T.
      • Gonzalez E.
      • Al-Razzo O.
      • et al.
      Results of the Patient-Related Outcomes of Mechanical lead Extraction Techniques (PROMET) study: a multicentre retrospective study on advanced mechanical lead extraction techniques.
      Current techniques rely on advancing sheaths over a targeted lead reinforced by a locking stylet; in the event of failure, the femoral approach is often used to complete the procedure in a “bail-out.”
      • Byrd C.L.
      • Schwartz S.J.
      • Hedin N.
      Intravascular techniques for extraction of permanent pacemaker leads.
      This does not guarantee success.
      The femoral approach in conjunction with a jugular approach has been used effectively and safely in difficult cases, pulling the lead downward and then upward,
      • Bongiorni M.G.
      • Soldati E.
      • Zucchelli G.
      • et al.
      Transvenous removal of pacing and implantable cardiac defibrillating leads using single sheath mechanical dilatation and multiple venous approaches: high success rate and safety in more than 2000 leads.
      ,
      • Bongiorni M.G.
      • Segreti L.
      • Di Cori A.
      • et al.
      Safety and efficacy of internal transjugular approach for transvenous extraction of implantable cardioverter defibrillator leads.
      but the method described by Bongiorni and colleagues is incompatible with the use of locking stylets and so is not routinely used with powered sheaths. The jugular vein has significant advantages: the distance from the access point to the heart is significantly shorter from the jugular than the femoral, and the course from access point to right ventricular apex is straighter from the jugular than from any other access.
      We describe a novel technique used to transfer the targeted lead from the original subclavian access to the right jugular vein with a deployed locking stylet in situ. In this case it allowed us to complete the extraction of a high-voltage lead that had resisted extraction by standard methods.

      Case report

      A 55-year-old man with a background of hypertrophic cardiomyopathy and dual-chamber implantable cardioverter-defibrillator (ICD) for primary prevention was admitted after multiple inappropriate shocks owing to electrical artefact on the right ventricle (RV) high-voltage lead (DX system; BIOTRONIK, Berlin, Germany). The RV lead had been implanted elsewhere 5 years earlier and an atrial lead added to permit atrial pacing 6 months before presentation.
      The patient was scheduled for extraction and replacement of the ICD system using a “Tandem” approach. Following induction of general anesthesia, a 13-mm Needle’s Eye Snare (Cook Medical, Bloomington, IN) was advanced from the right femoral vein to the right atrium. The device was freed from its left prepectoral pocket; the leads were dissected free, and the atrial lead was removed by gentle traction. After retraction of the fixation helix of the RV lead, a locking stylet (Liberator Beacon Tip; Cook Medical) was deployed and a compression coil was applied (OneTie; Cook Medical). An obstruction at the entrance to the shock coil prevented the locking stylet from reaching the lead tip.
      The Needle’s Eye Snare was used to grasp the lead in the right atrium and provide countertraction as the 13F Evolution RL (Cook Medical) was advanced over the lead (Figure 1). Upon reaching the right atrium, the lead was released from the snare to allow the dissecting tool to advance, but the lead began to unravel at the coil, halting any further advancement. The lead was repeatedly re-grasped with the snare in attempts to complete the extraction via the femoral access, but the disrupted coil prevented the lead from entering the outer sheath of the snare and moderate traction could not move the lead tip.
      Figure thumbnail gr1
      Figure 1A: The chest radiograph demonstrating the position of the targeted leads. B: The locking stylet only advanced as far as the shock coil, where it was deployed. The lead was withdrawn into the outer sheath of the Needle’s Eye Snare (Cook Medical). C: The Needle’s Eye Snare held the shock lead taut in the right atrium, providing countertraction as the Evolution RL sheath (Cook Medical) dissected down to the snare without difficulty. D: The lead coil de-spiraled after its release from the snare, halting progress of the dissecting sheath.
      The right internal jugular (RIJ) vein was accessed using a 20F sheath (Cook Medical) and a 25-mm Gooseneck snare (Medtronic, Minneapolis, MN) was passed through it to the superior vena cava (SVC) while the Evolution outer sheath preserved the subclavian vein access. A 0.032 guidewire (Abbott Medical, Abbott Park, IL) was passed through the Evolution outer sheath in the subclavian to the SVC, where it was snared by the Gooseneck and pulled out through the jugular sheath.
      A long 8.5F sheath (SL0; Abbott Medical) was advanced over the 0.032 wire through the jugular sheath, into the Evolution outer sheath alongside the targeted lead, and emerged from the sheath at the subclavian access site. The dilator of the SL0 sheath was removed, leaving the sheath to act as a tunnel connecting the jugular to the left subclavian access point. Via this tunnel, the 25-mm Gooseneck snare catheter was passed from the jugular site to surface at the subclavian side, where it was used to “collect” the free end of the locking stylet and pull it through to exit at the jugular site (Figure 2). The locking stylet, now at the jugular end, was grasped and used to pull the mobile segment of the lead into the SL0 sheath. Then the entire unit of SL0, locking stylet, and lead was pulled smoothly at the jugular access, transporting the stylet/lead unit safely from the subclavian site to emerge intact through the 20F jugular sheath. With the targeted lead now exiting the RIJ, the 13F dissecting sheath was advanced over it to the lead tip and the lead was extracted in its entirety. Access was retained and a new dual-chamber ICD was implanted without sequelae.
      Figure thumbnail gr2
      Figure 2A: After right jugular vein access was gained, a Gooseneck snare (blue star) was used to grasp the 0.032 guidewire positioned in the superior vena cava from the subclavian access and pull it out through the jugular vein sheath. B: An SL0 sheath was advanced over the 0.032 guidewire from the jugular to the subclavian, where it emerged. C: The Gooseneck catheter was passed through the SL0 to exit at the subclavian access where the locking stylet was directed into it as far as possible; retracting the Gooseneck catheter pulled the locking stylet and lead (white arrow) into the SL0 (black star). D: The SL0, with the lead and locking stylet engulfed within it, was retracted back at the jugular, where it all surfaced. E: With a straightened railroad from the jugular, the rotational dissecting sheath was advanced to the lead tip to dissect the tip free and exert counter-pressure to complete the extraction. F: The extracted lead and locking stylet, demonstrating the unraveled coil.

      Discussion

      We describe a novel subclavian-to-jugular pull-through technique that provided a safe and effective method for transferring a lead and locking stylet, as a unit, from the subclavian access point to the jugular (Supplemental Video; Figure 3). It represents an adaptation of the Bongiorni technique that allows a locking stylet to remain fully deployed in the lead and usable after the transfer of the access site. In this case, the transfer to the jugular was key to successfully completing the extraction. Switching to the RIJ straightened the lead, allowing previously impossible progress of the Evolution sheath to apply counter-pressure at the lead tip. Owing to the angulated course of the lead, sheaths of similar size advanced from the subclavian or the femoral had made no progress.
      Figure thumbnail gr3
      Figure 3A: A Gooseneck snare from the right jugular vein was used to grasp the 0.032 guidewire (red) parked in the superior vena cava from the subclavian access, which was preserved using the outer sheath of the dissecting tool. The wire was pulled out through the jugular vein sheath (yellow). B: An SL0 sheath (green) was advanced over the 0.032 guidewire from the jugular to exit at the subclavian access. C: The SL0 sheath behaves as a “tunnel” connecting the subclavian and jugular access points. The free handle of the locking stylet was directed into the exposed SL0 sheath. D: The locking stylet handle emerged at the jugular end, which was used to pull the whole of the stylet and attached lead into the SL0 at the subclavian; no metal was exposed in the vasculature. E: The SL0, with the locking stylet and lead engulfed within it, was retracted back at the jugular, where it all surfaced. F: The rotational dissecting tool (black) was advanced successfully over the straightened railroad from the jugular, to complete the extraction.
      Traction applied to a lead permits a dissecting tool to follow that lead through the tortuosity of the vasculature.
      • Akhtar Z.
      • Sohal M.
      • Starck C.T.
      • et al.
      Persistent left superior vena cava transvenous lead extraction: a European experience.
      From the subclavian access, the angulations passed to reach the ventricular apex are considerable. A locking stylet, particularly when combined with fixation of the lead in the atrium in the “Tandem” approach, permits enough force to overcome most of the tortuosity in the majority of cases. The enhanced countertraction from the “Tandem” may also pull the lead away from the SVC wall, reducing cardiovascular injury,
      • Muhlestein J.B.
      • Dranow E.
      • Chaney J.
      • Navaravong L.
      • Steinberg B.A.
      • Freedman R.A.
      Successful avoidance of superior vena cava injury during transvenous lead extraction using a tandem femoral-superior approach.
      but the technique only helps as far as the right atrium. From the right atrium to point of RV lead attachment, one additional angle must be crossed without the assistance of the snare. The linear course from jugular to RV apex can help; transferring the lead to the jugular vein reduces this last angle. For leads attached in the RV outflow tract, a femoral approach would provide more favorable angles, but the current powered sheaths are not adapted to this application.
      The jugular approach has historically been applied to free-floating leads or leads that are converted to “free floating” by pull-down from the femoral vein.
      • Bongiorni M.G.
      • Soldati E.
      • Zucchelli G.
      • et al.
      Transvenous removal of pacing and implantable cardiac defibrillating leads using single sheath mechanical dilatation and multiple venous approaches: high success rate and safety in more than 2000 leads.
      ,
      • Bongiorni M.G.
      • Segreti L.
      • Di Cori A.
      • et al.
      Safety and efficacy of internal transjugular approach for transvenous extraction of implantable cardioverter defibrillator leads.
      Leads with a fully deployed locking stylet cannot safely be rendered free floating; the handle end of the device is designed for heavy work outside the body, not exposure to endovascular surfaces. Our jugular pull-through technique was adapted from the Bongiorni technique via the “triple venous access” method
      • Akhtar Z.
      • Zaman K.U.
      • Leung L.W.
      • Zuberi Z.
      • Sohal M.
      • Gallagher M.M.
      Triple access transvenous lead extraction: pull-through of a lead from subclavian to jugular access to facilitate extraction.
      and overcomes these limitations. The use of the SL0 sheath to act as the transfer vehicle between the jugular and subclavian veins was crucial—it protected the vessels from injury by exposed metal. The length of the SL0 was also valuable, as it ensured that both ends of the sheath remained externalized. This allowed control of the “vehicle” and ensured that the full length of the locking stylet was engulfed within the sheath. The 8.5F internal diameter of the SL0 was sufficient to contain the end of this high-voltage lead and transport it from one access to the other. Larger sheaths of similar length are available.
      The advantage of the subclavian-to-jugular pull-through over the Bongiorni method is that it permits transfer of a fully deployed locking stylet from one access to the other. The locking stylet remains usable and provides the length and enhanced tensile strength to help the passage of a dissecting tool over the lead, and to limit lead disintegration.
      • Vatterott P.
      • De Kock A.
      • Hammill E.F.
      • Lewis R.
      Strategies to increase the INGEVITY lead strength during lead extraction procedures based on laboratory bench testing.
      Conventionally, the locking stylet is deployed early in a procedure; from that point, abandonment of the procedure or conversion to another access site becomes difficult, as the stylet is not always easy to remove. Our technique provides a route to overcome this limitation. It permits the operator to use their conventional extraction approach with confidence, always retaining the option of switching to the jugular, if the need arises.

      Mistakes

      In this case we used a 20F sheath for jugular access, a sheath that proved too small to allow the passage of the 13F Evolution RL outer sheath. We therefore had to remove this sheath and pass the Evolution tool directly through the skin. The size of the access channel prepared by the 20F sheath made this reasonably easy. In other cases, we have used a 23F jugular sheath and have found that the outer sheath of the 13F Evolution passed through without difficulty; the 23F sheath is a more elegant solution but was unavailable on the day of the case described.
      The de-spiraling of the shock coil in this case could be interpreted as evidence of rough handling in the form of either excessive traction or excessive compression by the needle-eye snare. We do not believe that either of these occurred; we take the electrical malfunction of the lead, the apparent obstruction encountered by the locking stylet, and the de-spiraling at the same point as evidence of prior lead damage at this site. By the time it had been removed the lead was too damaged to test this hypothesis.

      Limitations

      The pull-through of this lead added to the long procedural and fluoroscopy time, so the technique is not suitable for widespread routine use. In this case, repeated unsuccessful attempts to extract the lead by conventional means had already consumed a lot of time, and we might have succeeded sooner if we had switched to this approach earlier.
      This technique requires at least 2 operators with experience in transvenous lead extraction, which may not be possible in low-volume centers. This technique was used as a “bail-out” in our case but could be used as a method of choice in selected difficult cases, which may include leads with a very prolonged dwell time, leads that are prone to disintegration, or patients with unfavorable anatomy.

      Conclusion

      The subclavian-to-jugular pull-through technique enables safe transfer of lead and stylet from the subclavian to the jugular access to facilitate complete lead extraction. It was used as a “bail-out” option in our case but has potential for wider application.

      Appendix. Supplementary data

      Key Teaching Points
      • Transvenous lead extraction from the conventional subclavian approach may be challenging as a result of the angulations presented by the vasculature.
      • Transferring the targeted lead to the jugular access can overcome the difficult angulations to facilitate successful extraction; the path is linear from the jugular access to the lead tip. However, endovascular transfer of the lead with a fully deployed locking stylet may not be feasible owing to the risk of injury to the large vessels.
      • Our novel jugular pull-through technique permits safe transfer of the targeted lead, with a fully deployed stylet, from the subclavian to the jugular access to facilitate extraction.

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