Corti, R.

Stähli, B.E.

Wyss, C.A.

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Case reportA hybrid ICD extraction approach using laser andtransfemoral extraction techniqueB.E. STA¨HLI, C.A. WYSS and R. CORTIFrom the Cardiovascular Center, Cardiology, University Hospital Zurich, Zurich, SwitzerlandAddress correspondence to Dr R. Corti, Andreas Gru¨ntzig Catheter Laboratories, Cardiovascular Center,Cardiology, University Hospital Zu¨rich, Ra¨mistrasse 100, 8091 Zu¨rich, Switzerland. email: roberto.corti@usz.chIndications for pacemaker and implantable cardio-verter defibrillator (ICD) implantations are rapidlyexpanding. Hence, device-related complicationshave increased the need for lead extraction. Leadextractions are performed percutaneously or byopen surgery.We present a patient with isolated left ven-tricular noncompaction cardiomyopathy sufferingfrom ICD pulse generator pocket and lead infectionwith aggregatibacter actinomycetem comitansbacteremia. The complete device was successfullyremoved by a hybrid two-step approach usingexcimer laser and transfemoral lead extraction tech-nique in combination with mechanical traction viathe subclavian vein. Thereby, open surgery withpossible need for cardiopulmonary bypass couldbe avoided in this patient.Case presentationA 55-year-old male was referred to the hospital dueto exertional dyspnea, fatigue and pain in the ICDpulse generator pocket. ICD implantation was per-formed due to sustained ventricular tachycardiain isolated left ventricular noncompaction cardio-myopathy 10 years ago. ICD pulse generator wasreplaced due to battery depletion 3 years ago.On admission, the patient was hemodynamic-ally stable, and the ICD pulse generator pocketwas reddened and swollen. Laboratory chemistryrevealed slightly elevated C-reactive protein levels(22mg/l). No intracardiac vegetations were visua-lized by transesophageal echocardiography, leftventricular noncompaction was documented witha left ventricular ejection fraction of 51%.Coronary computed tomography revealed normalcoronary arteries. The ICD pulse generator pocketwas punctured and purulent material could be aspi-rated. Hence, diagnosis of ICD pulse generatorpocket infection with possible lead infection wasmade. Tissue debridement, and extraction of theICD pulse generator, the atrial lead and the distalpart of the ventricular lead insulation were per-formed with excimer laser-assisted extraction tech-nique in the operating room 3 days after admission.However, the ventricular lead, the proximal part ofthe insulation and the conductor coil could not beremoved and were left in place (Figure 1).Postoperatively, antibiotic therapy with vancomycinand ciprofloxacine was administered. The ventricu-lar lead with its insulation and the conductor coilwere extracted in the cardiac catheter laboratory4 days later. Both, the ventricular lead and its insu-lation were removed by transfemoral venous accessunder fluoroscopy using a DRS-100 basket (COOKMedical Inc., Bloomington, IN, USA) as retrieverdevice. Having inserted an eight French femoralsheath, the preloaded basket retriever device wasadvanced to the heart and opened to grab the ven-tricular lead with its insulation. After grasping thelead, the basket was closed to fix the lead and trac-tion was applied to pull it from the heart to theinferior vena cava and remove it from circulation(Figure 2). The lead was pulled out with the sheaththrough a small cutaneous incision, the vein wascompressed manually for five minutes and definite! The Author 2011. Published by Oxford University Press on behalf of the Association of Physicians.All rights reserved. For Permissions, please email: journals.permissions@oup.comQ J Med 2012; 105:265–268doi:10.1093/qjmed/hcq256 Advance Access Publication 22 January 2011hemostasis was completed by a cutaneous Z-suture.The ingrown conductor coil was unwinded via thesubclavian vein by mechanical traction with aclamp through the surgically reopened ICD pulsegenerator pocket after coil location under fluoro-scopic visualization (Figure 2D). Hence, both theventricular lead with its insulation and the conduct-or coil, could successfully be removed (Figure 3),and open surgery with possible need for cardiopul-monary bypass could be avoided in this patient. Inthe course, aggregatibacter actinomycetem comi-tans was isolated from several blood cultures, thematerial obtained by puncture of the ICD pulse gen-erator pocket, and the extracted device and antibiot-ic therapy was changed to ceftriaxone.In the course, elevated C-reactive protein levelsnormalized and the patient fully recovered andcould be discharged 10 days after admission. Onemonth after lead extraction, a new ICD was success-fully implanted.CommentWe describe the first case of a two-step hybrid ICDlead extraction approach using excimer laser andtransfemoral extraction technique in combinationwith mechanical unwinding of the ingrown con-ductor coil via the subclavian vein.Figure 2. Extraction sequences of venticular transfemoral lead removal with a retreiver basket. (A and B) Retriever basketremoving the grasped lead from the heart to the inferior vena cava. (C) Retriever basket with the grasped lead in the iliacalvein. (D) Unwinding of the conductor coil via the subclavian vein by mechanical traction.Figure 1. Chest X-ray with ventricular lead, leadinsulation and conductor coil left in place.266 B.E. Sta¨hli et al.Pacemaker and ICD implantation rates have rap-idly been increasing over the past decades. In thecourse, increased device-related complicationshave raised the need for device removal.Device-associated infections are the commonest in-dication for complete device removal having beenreported in 0.9–19.9% of patients.1 Further indica-tions for device removal are risk of lead fracture,chronic pain, thromboembolic events associatedwith thrombus material attached to the lead andlife-threatening arrhythmias secondary to leaddysfunction.2Lead extraction is performed either by an opensurgical or a percutaneous approach using differentremoving systems such as electrocautery dissectionsheaths, excimer laser or transfemoral extraction de-vices. Manual or mechanical traction is often suffi-cient to remove leads implanted a few months ago;however, due to fibrous attachment to surroundingstructures, advanced extraction devices are used forremoval of devices that have been implanted foryears. Percutaneous technique is favored aboveopen surgery because of its lower morbidity andmortality. Indeed, most leads can completely beremoved percutaneously, success rates of 88–97%have been reported.3 However, open surgery has tobe discussed in patients presenting with large leadvegetations and tricuspid valve vegetations due tothe substantial risk of embolization. Furthermore,open surgery is required if complete percutaneousremoval has failed in patients with systemicdevice-related infections. Predictors of major pro-cedural complications are long implantation time,female gender, ICD lead removal and the use oflaser extraction techniques.2 Interestingly, elevatedpreprocedural C-reactive protein levels have beenassociated with increased acute in-hospitalmortality.4Apart from the venous entry site, both, the jugularand the femoral vein, can be used to gain venousaccess for percutaneous lead removal. Differentfemoral extraction devices such as deflectingwires, dotter retrievers and wire loop snares havebeen described.5 One of the earliest transfemorallead extraction was preformed using a pigtail cath-eter to grab the lead and pull it into the inferior venacava, where it was snared with a dotter retriever andremoved form circulation.6 In our patient, an eightFrench basket retriever was used for extraction of theventricular lead.Hence, hybrid approaches using different percu-taneous lead extraction systems such as excimerlaser and transfemoral extraction devices, possiblycombined with manual or mechanical traction viathe subclavian vein, as with our patient, can safelybe performed and may avoid the need for opensurgery.Conflict of interest: None declared.References1. Phibbs B, Marriott HJ. Complications of permanent transve-nous pacing. N Engl J Med 1985; 312:1428–32.2. Wilkoff BL, Love CJ, Byrd CL, Bongiorni MG, Carrillo RG,Crossley GH, et al. Transvenous Lead Extraction: heartrhythm society expert consensus on facilities, training, indi-cations, and patient management. Heart Rhythm 2009;6:1085–104.Figure 3. (A) Open retriever basket with removed ICD lead and fibrous adhesions. (B) Closed retriever basket with removedICD lead and fibrous adhesions. (C) Removed conductor coil of the ventricular lead with fibrous adhesions.A hybrid ICD lead extraction approach 2673. Rusanov A, Spotnitz HM. A 15-year experience with per-manent pacemaker and defibrillator lead and patch extrac-tions. Ann Thorac Surg 2010; 89:44–50.4. Hamid S, Arujuna A, Ginks M, McPhail M, Patel N,Bucknall C, et al. Pacemaker and defibrillator leadextraction: predictors of mortality during follow-up. PacingClin Electrophysiol 2010; 33:209–16.5. Belott PH. Lead extraction using the femoral vein. HeartRhythm 2007; 4:1102–7.6. Espinosa RE, Hayes DL, Vlietstra RE, Osborn MJ,McGoon MD. The Dotter retriever and pigtail catheter: effi-cacy in extraction of chronic transvenous pacemaker leads.Pacing Clin Electrophysiol 1993; 16:2337–42.268 B.E. Sta¨hli et al.

A hybrid ICD extraction approach using laser and transfemoral extraction technique

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