A 61-year-old patient with a 20-year history of permanent pacemaker implantation and half-
-a-year cardiac resynchronization therapy using a left ventricular lead placed via surgical
approach was admitted for extraction of an old coiled right ventricular lead, which triggered
ventricular arrhythmia and created a risk of pulmonary embolism. The lead was extracted via
the left femoral vein in two stages: untying a loop on the lead using a pig-tail catheter and
Dotter basket followed by traction and dissection of adhesions using a Byrd dilator sheath.
Dissection of the old lead from the active right ventricular one posed special technical problems

Bednarek, Jacek

Kutarski, Andrzej

Lelakowski, Jacek

Małecka, Barbara

Ząbek, Andrzej

English

Via Medica Journals

www.cardiologyjournal.org 371CASE REPORTCardiology Journal2008, Vol. 15, No. 4, pp. 371–375Copyright © 2008 Via MedicaISSN 1897–5593Address for correspondence: Barbara Małecka, Departament of Electrocardiology, Cardiology Institute CMUJ, John Paul IIHospital, Prądnicka 80, 31–202 Kraków, Poland, e-mail: barbara_malecka@go2.plReceived: 17.11.2007 Accepted: 22.04.2008Percutaneous extraction of a coiled,20-year-old lead in a patient withcardiac resynchronization therapyBarbara Małecka1, Andrzej Kutarski2, Jacek Bednarek1,Andrzej Ząbek1 and Jacek Lelakowski11Departament of Electrocardiology, Cardiology Institute CMUJ, John Paul II Hospital, Kraków, Poland2Chair and Department of Cardiology, Medical Academy, Lublin, PolandAbstractA 61-year-old patient with a 20-year history of permanent pacemaker implantation and half--a-year cardiac resynchronization therapy using a left ventricular lead placed via surgicalapproach was admitted for extraction of an old coiled right ventricular lead, which triggeredventricular arrhythmia and created a risk of pulmonary embolism. The lead was extracted viathe left femoral vein in two stages: untying a loop on the lead using a pig-tail catheter andDotter basket followed by traction and dissection of adhesions using a Byrd dilator sheath.Dissection of the old lead from the active right ventricular one posed special technical problems.(Cardiol J 2008; 15: 371–375)Key words: percutaneous lead extraction, permanent pacingCase reportA 61-year-old female patient presenting withsick sinus syndrome received a permanent cardiacpacemaker 20 years ago. Because of myopotentialinhibition of the unipolar passive fixation ventricularlead (Siemens Elema 411/60), the patient receiveda new bipolar ventricular lead (Biotronik SX 60)9 years ago. The old electrode was deactivated andsewn to the fibrous wall of the pacemaker pocket.One year later dual chamber pacing was abandonedbecause of chronic atrial fibrillation development.The atrial lead (Medtronic 4504M) was deactivatedduring pacemaker replacement.The pacing system was changed to a biventri-cular cardiac resynchronization therapy one, due toNYHA class III heart failure, left ventricular ejec-tion fraction (LVEF) of 30% and symptoms of con-traction dyssynchrony. As chest X-ray revealeda coiled old lead, the venous approach was abando-ned and a left ventricular lead (Medtronic SuturLess MYO) was advanced via left-sided microtho-racotomy. The dislodgement and coiling of the leadprobably occurred a year before — an approximatedate was provided by analysis of chest X-rays andechocardiograms (Fig. 1A, B). Cardiac resynchroni-zation therapy installation resulted in a significant he-modynamic improvement (NYHA class II and LVEF44%) and the patient was referred for extraction ofthe inactive, coiled old lead. Indications for the pro-cedure included ventricular arrhythmia necessitatingadministration of amiodarone with beta-blocker, andadditionally increased risk of pulmonary embolism.The lead extraction was carried out under lo-cal anesthesia with 1% Xylocaine. Its proximal endremained in the vein whereas the distal end hadgrown firmly into the right ventricular wall in thevicinity of the active right ventricular lead tip.A Byrd Workstation Femoral 16 F was intro-duced subsequently via the left femoral vein. Then372Cardiology Journal 2008, Vol. 15, No. 4www.cardiologyjournal.orga successive pig-tail Launcher Guiding Catheter(Medtronic LAA8JR40) was introduced. The proxi-mal end of the lead was snared at the right atriallevel and pulled down to untie the loop (Fig. 2A–E).Subsequently, the Dotter Helical Loop Basket(Cook Medical 12 F) was used to grasp the proxi-mal lead end which was previously liberated anddetached from the venous inner wall (Fig. 2F). Fi-nally it was exteriorized with direct traction. Thedistal tip of the old lead was dissected from themyocardial tissue by manual application of force asa result of the traction, but it remained attached tothe active right ventricular lead by the mobilizedpiece of fibrous tissue (Fig. 3A–D). A Byrd DilatorSheath Polypropylene Yellow Extra Long was cho-sen as the tool to separate the leads that were se-aled with the mass of fibrous tissue (Fig. 3B–E).Available, published scientific descriptions did notprovide any data concerning such usage of this de-vice, which had been widely used to separate leadsfrom intravascular adhesions to the venous wall andintracardiac adhesions to endocardial surfaces. Bothdescribed applications were obtained with accessthrough the subclavian or jugular veins, and regar-ded the leads with free ends, accessible within thepacemaker pockets.Although it was reasonable, and in some wayelegant, to introduce the recommended locking sty-let through the lead internal lumen, the disintegra-tion of the coil by hitherto manoeuvres like stret-ching and pressing by pig-tail as well as basket ca-theters, occluded the lumen. It disabled introductionand usage of the locking stylet. Its functional equ-ivalent became the lead itself, and the long threadsattached to the proximal end which was exteriori-zed through Byrd Workstation. The threads weretied to the lead end using the original knots. Thepolypropylene sheath was then introduced intrave-nously over the threads with the lead, being pulledout simultaneously. The last one played the role ofFigure 1. PA and lateral fluoroscopic image before the removal, showing three endocardial leads: deactivated atriallead, active ventricular lead, and the old broken ventricular lead, pulled and coiled within the right ventricle (A, B). PAand lateral fluoroscopic image after removal. The only endocardial leads are: Deactivated atrial lead and the activeventricular lead. The epicardial lead screwed on the left ventricle shown clearly on the lateral images (C, D). Arrows:A — inactive atrial lead; B — active right ventricular lead; C — active left ventricular lead; D — looped ventricularlead “without free end”.373Barbara Małecka et al., Percutaneous extraction of a coiled, 20-year-old lead in a patient with CRTwww.cardiologyjournal.orgspecific guide-wire (Fig. 3B–E). The constructionconsisting of the Byrd Dilator and the lead withextended threads inside created the intravascularcountertraction with the lead system. The extrac-tion force was initially applied to the threads and tothe proximal lead end thereafter, with the simulta-neous countertraction pushing with the sheath. OnFigure 2. PA, fluoroscopic image. A. The proximal end of the extracted lead entrapped in the vena cava superior;meanwhile, the distal one to the right ventricular endocardium. The pig-tail Launcher guiding catheter (MedtronicLAA8JR40) introduced by femoral approach, in the early phase of wrapping over the looped lead in the right atrium;B. The pig-tail catheter untying the loop in the right ventricle; C. The pig-tail catheter pulling down the loop towardsthe inferior vena cava; D. The pig-tail catheter stretching the loop at the sub-phrenic level of the vena cava inferior;E. The proximal end of the lead detached from the vena cava superior wall, directed towards its bifurcation. Theattempt to catch the lead end with the Dotter basket. The lead shade overlaps the shade of the additional intravascu-lar stylet; F. The proximal end snared and pulled by the Dotter basket towards the Byrd Workstation in the leftfemoral vein. Arrows: A — atrial lead; B — active right ventricular lead; C — intrapericardial loop of left ventricularlead; D —– extracted lead “without free end”; 1 — pigtail; 2 — additional intravascular stylet; 3 — opened Dotterbasket; 4 — locked Dotter basket.X-ray the old lead was hung on the active one bendwithin the right atrium (Fig. 3C). The extracted leadwas dissected parallel to the active one by repeatedmanipulation with the sheath, without causing anydamage to the latter. Rotational movements of thesheath to free the adhesion could result in pullingout the active right ventricular lead while floating374Cardiology Journal 2008, Vol. 15, No. 4www.cardiologyjournal.orgFigure 3. PA, fluoroscopic image. The dissection of the distal tip of the old lead from the myocardial tissue duringtraction applied via the Dotter basket (A, B). The separation of the two endocardial ventricular leads, sealed by themobilized mass of fibrous tissue, using the Byrd dilator (C, D, E, F). Arrows: A — inactive atrial lead; B — active rightventricular lead; C — looped left ventricular “screw-on” lead; D — distal fragment of inactive right ventricular lead.free in the right atrium and causing no resistance(Fig. 3D). But finally we managed to exteriorize theinactive lead completely without any complications(Fig. 1E, D). However, we finally managed to exte-riorize the inactive lead completely without anycomplications.  The femoral Byrd Workstation wassubsequently removed entirely.DiscussionThe lead in the present case was removed viathe femoral vein approach, which is recommendedfor extraction of leads older than one year and di-slodged into cardiac cavities [1–3]. The extractedlead had remained in the heart for 20 years and co-iled for over a year. The patient required antiarr-hythmic treatment due to multiple ventricular pre-mature beats, probably provoked by the abandonedlead irritating the tricuspid area and right ventricu-lar outflow tract. Echocardiograms did not revealany thrombus formation on the lead, but pulmona-ry microembolization could not be excluded [4]. Anadditional interesting aspect of the procedure wasthe postponement of lead removal until clinical375Barbara Małecka et al., Percutaneous extraction of a coiled, 20-year-old lead in a patient with CRTwww.cardiologyjournal.orgimprovement outcome, after cardiac resynchroni-zation therapy introduction via a surgical approach.The problems encountered during the procedurerelated to the vicinity of the active right ventricu-lar lead over which the extracted lead was hangingwith a piece of fibrous tissue torn off the endocar-dium. The leads were dissected using a Byrd dila-tor sheath. To our knowledge, it is probably the firstusage of the Byrd Dilator Sheath introduced thro-ugh the inferior femoral vein. The access previo-usly used was obtained only through subclavian andjugular veins [2, 5–8].Transvenous removal was safely and success-fully performed using a Cook Medical device (ByrdWorkstation Femoral 16 F, Dotter basket 12 F andByrd Dilator Sheaths Polypropylene Yellow, 13.9 F)with pig-tail Medtronic catheter.Conclusions1. Extraction of a coiled old lead via a transveno-us femoral approach can be a feasible and safemethod.2. Separation of coexistent endocardial leads, se-aled by fibrous tissue, can also be performedusing the femoral vein approach.AcknowledgementsThe authors do not report any conflict of inte-rest regarding this work.References1. Byrd CL, Belott PH, Brinker JA et al. Recommendations forextraction of chronically implanted transvenous pacing anddefibrillator leads: Indications, facilities, training. PACE 2000;23 (Part I): 544–551.2. Klug D, Jarwe M, Messaoudene SA et al. Pacemaker lead ex-traction with the Needle’s eye snare for countertraction viaa femoral approach. PACE, 2002; 25: 1023–1028.3. Tyers GFO. Similar indications but different methods: Shouldthere be a consensus on optimal lead extraction techniques?PACE, 2002; 25:1019–1022.4. Bohm A, Pinter A, Duray G et al. Complications due to abandonednoninfected pacemaker leads. PACE, 2001; 24: 1721–1724.5. Bracke F, Meijer A, van Gelder B. Extraction of pacemaker andimplantable cardioverter defibrillator leads: Patient and leadcharacteristics in relation to the requirement of extraction tools.PACE, 2002; 25: 1037–1040.6. Byrd CL, Wilkoff BL, Love CJ et al. Intravascular extraction ofproblematic or infected permanent pacemaker leads: 1994–1996.PACE, 1999; 22: 1348–1357.7. Manolis AS, Maounis TN, Vassilikos V, Chiladakis J, Melita--Manolis H, Cokkinos DV. Ancillary tools in pacemaker anddefibrillator lead extraction using a novel lead removal system.PACE, 2001; 24: 282–287.8. Rosenheck S, Weiss A, Leibowitz D, Sharon Z. Noninstrumentalpacemaker and defibrillator lead removal. The importance of therotation forces. PACE, 2002; 25: 1029–1036.

Percutaneous extraction of a coiled, 20-year-old lead in a patient with cardiac resynchronization therapy

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Percutaneous extraction of a coiled, 20-year-old lead in a patient with cardiac resynchronization therapy

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