PACING
Transjugular approach for lead extraction
Cardiology Division, Hospital Juan A. Fernández, Cerviño 3356, CP 1425 Buenos Aires, Argentina
Manuscript submitted 9 March 2007. Accepted after revision 25 November 2007.
* Corresponding author. Tel: +54 11 4241 4140; fax +54 11 4240 1071. E-mail address: hmazzetti{at}intramed.net.ar
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Abstract |
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Aims: The purpose of this manuscript is to describe a transjugular extraction technique which permits the use of locking stylets and sheaths, for leads previously cut and retracted into the venous system and/or damaged during an extraction performed via the superior approach.
Methods and results: A horizontal cervical incision is made over the sternocleidomastoid muscle to access the internal jugular vein between both fascicles of the muscle. The vein is ligated and through a phlebotomy a pig-tail catheter or the laparoscopic tool is introduced into the jugular vein. At the end of the procedure, a second ligature is also applied. This technique was utilized in 18 patients for the extraction of 22 leads with a mean implant duration of 91.8 months (range from 12 to 285 months). The age of the patients ranged from 19 to 87 years, (mean = 58.6 years). Out of the 22 leads extracted, 14 were ventricular pacemaker leads, 5 atrial pacemaker leads, 2 ICD leads, and 1 ventricular lead for VDD pacing. As regards the extractions, 18 were complete, 2 tips were abandoned (partial extractions), and 2 failed.
Conclusion: This technique is especially useful if the leads to be extracted were previously cut and had retracted into the central circulation. Although our experience is based only on 18 patients and 22 leads, we can conclude that the success rate we have achieved was high and the complication rate was very low.
Key Words: Lead extraction, Transjugular approach, Laparoscopic tools
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Introduction |
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Extraction of permanent pacemaker, ICD, and coronary sinus leads is a procedure used with increasing frequency given the growing number of implantable devices.1
Leads are most commonly extracted by accessing them from the pacemaker implant site, (superior approach). This approach allows the use of locking stylets and passive and/or active sheaths. If the leads are no longer accessible from the implant site because they have been previously transected and allowed to retract into the venous system, the femoral approach can be used.2 However, with this technique, it is not possible to use locking stylets. The purpose of this manuscript is to describe a transjugular extraction technique using two grasping laparoscopic tools that allow the use of locking stylets and sheaths. This applies to leads previously cut and retracted into the venous system and/or broken during an extraction performed via the superior approach and/or leads with the conductor obstructed.
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Methods |
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Lead extraction procedure
A horizontal cervical incision is made over the sternocleidomastoid muscle to access the internal jugular vein between both fascicles of the muscle. The vein is ligated to avoid any damage due to the thorax proximity and through a phlebotomy a pig-tail catheter or the laparoscopic tool is introduced into the jugular vein. Since a surgical incision was performed, a purse-string may be used to avoid permanent vein ligation but this manoeuver does not facilitate the procedure. At the end of the procedure, a proximal ligature is also applied. We do not use introducers for these procedures. We prefer to have the vein ligated and well observed, because we are very near the thorax and any damage of the jugular vein would be very dangerous. Many times the tip of the lapascopic tool needs to be moved a few centimetres after its introduction and introducers are longer than the distance needed to move the tip. Many times we have to introduce the laparoscopic tool more than once, and loosing the approach would be detrimental.
The purpose of the pigtail catheter is to engage the retracted lead, whether it is in the right subclavian vein, left innominate vein, superior vena cava, right atrium, inferior vena cava, right ventricle, or pulmonary artery.3,4 With this catheter (Figure 1B and C) the lead is gently drawn into the superior vena cava. Through the same venous access site, a grasping tool (Figure 1D–F), normally used during laparoscopic procedures, is subsequently introduced. With this tool the lead is grasped, and exteriorized via the internal jugular vein. A variety of widely available, market-approved laparoscopic grasping tools may be used.
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The laparoscopic tools included: a Hasson 360 Endoscopic Grasping Forceps, manufactured by Cook Group, Leichburg, USA, in eight patients. This is a 5 mm (15 Fr) device, 30 cm long, with one action jaw, one component (Figure 2A–C). In another 10 patients, a Vancaillie Oviduct Forceps (Figure 3A), a 5 mm (15 Fr) device with a working length of 36 cm and double action jaws (Vancaillie Oviduct Forceps(Figure 3B), which disassembles into three components: Metal handle with Manhes style ratchet (Figure 3C), outer tube insulated, and forceps insert, manufactured by Karl Storz GMBH & Co. KG, Tuttlingen, Germany, was used. This device is different to Cook's, because it has a double action jaw for grasping the lead and can be rotated 360° without moving the handle. Once the lead is grasped, there is no need to apply any additional force to maintain the grasp of the lead due to the metal handle with Manhes style ratchet.
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If the leads are in the right subclavian vein, left innominate vein, superior vena cava, right atrium (Figure 4A, B, G), or inferior vena cava, they may be caught directly with the grasping tool. Once the lead is exteriorized, all the tools normally available for the superior extraction approach can be used. Lead extraction was considered complete when it has been entirely removed. Lead extraction was considered partial when some portions with a size of <4 cm could not be removed, but the clinical problem has been solved. If the lead could not be removed, or larger portions were abandoned, and/or if the clinical problem persisted, it can be considered as an extraction failure.
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Results |
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The transjugular approach described earlier was applied in 18 patients for the extraction of 22 leads with mean implant duration of 91.8 months (range from 12 to 285 months). The age of the patients ranged from 19 to 87 years (mean = 58.6 years). Out of the 22 leads extracted, 14 were ventricular pacemaker leads, 5 atrial pacemaker leads, 2 ICD leads, and 1 ventricular pacing lead with orthogonal atrial sensing for VDD pacing. There were four primary extractions (primary extraction procedure, via the implant approach with a damage of the lead during the procedure, continuation, and transjugular extraction). The other 18 leads were performed on patients referred from other centres as a consequence of failures in previous extraction attempts.
Indications for lead extraction via the transjugular approach included: (a) 5 cases (4 ventricular leads and 1 single AV lead) where a conventional extraction procedure had been attempted but a significant intravascular portion of the lead could not be removed since it was damaged during the procedure. The extraction was successfully completed using the transjugular approach; (b) One lead damaged during a previous procedure was thrombosed within the superior vena cava (ICD lead) (Failure). (Table 1); (c) Two leads that had the lumen obstructed. (Table 1); (d) Retracted leads: into right pulmonary artery (1 lead, Figure 1A; Table 1), suprahepatic vein (1 lead), right atrium (4 leads, Figure 4A), right subclavian vein (1 lead), left subclavian vein (2 leads, 1 of which had a retained locking stylet from a previous failed lead extraction attempt), superior vena cava (2 leads) (Table 1).
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Locking stylets could not be inserted in 2 leads, and 6 leads were engaged and exteriorized directly with the laparoscopic tool.
In two cases it was not possible to grasp the lead within neither superior vena cava nor subclavian vein, possibly because of severe scarring around the lead.
Complete or total extractions were accomplished in 18 leads, 2 tips were abandoned (1 atrial and 1 ventricular) and 2 failed (one ICD lead due to superior vena cava thrombosis and one ventricular lead covered by scar tissue, at the SVC/right subclavian junction).
Complications
Complication occurred in one of the 18 patients (5.6%). In this patient a fistula formed between the pulmonary artery and bronchus. The abandoned lead had perforated the pulmonary artery entering a bronchus. After removing the lead, a fistulous tract remained between the pulmonary artery and bronchus, leading to haemoptysis. The only procedure required for this patient was mechanical respiratory assistance with subsequent clinical improvement in discharge. The patient remained in the intensive care unit for a month.
Despite the large diameter (15 Fr) of the laparoscopy tool used, no significant blood loss or bleeding complications occurred in any patient and no transfusions were required.
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Discussion |
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In this paper we describe the transjugular approach for abandoned pacemaker and ICD leads. Although there are several circumstances in which this technique may be employed, it is especially useful if the leads to be extracted were previously cut and had retracted into the central circulation. The tips of all leads were in the original position, except those in which the transjugular approach was attempted immediately after the failure of a superior approach. Leads with the lumen obstructed had previous extraction attempt, one was cut and abandoned and the second was left complete in the pocket.
The success rate we have achieved was high and the complication rate was very low.
Leads that require extraction but are non-accessible through the implant site can be extracted by several techniques.
The femoral approach was the first to be used with pigtail catheters, deflecting wires, baskets, needle-eye snare, etc. With this technique the use of locking stylets is not possible, so simple traction is applied from the point where the lead is engaged by one of these tools and/or catheters. There are systems that allow the use of telescoping sheaths, but negotiating the right angle between the inferior vena cava and the right ventricle can be difficult, even though, with good results. Many extractionists have good results with the needle-eye snare, but it is not available in our country.
It may be possible that the use of LASER sheaths5 would have allowed successful and complete extraction of leads in cases 2,3,4 and 5, obviating the need of a transjugular approach but this technology is not available for us.
The transatrial approach is well proved, but it has to be performed by cardiothoracic surgeons. We use this approach for those leads that are retracted and could not be exposed through the internal jugular vein.6 Bongiorni et al.7 described a transjugular approach using similar tools to those used for the femoral approach.
Once the lead is visible through the vein, a locking stylet is inserted and sheaths can progress easily because there are practically no bends to negotiate.
One difficulty with this approach has been observed in patients with superior vena cava thrombosis and leads that were completely embedded in dense fibrotic tissue preventing the leads from being grasped with the laparoscopic tool and therefore impossible to remove. It might be possible that pre-procedural superior vena cava venography would help predict this circumstance.
The complication rate in this group of patients was extremely low and the tools used are readily available in any country.
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Conclusion |
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This technique is especially useful if the leads to be extracted were previously cut and had retracted into the central circulation. Although our experience is based only on 18 patients and 22 leads, we can conclude that the success rate we have achieved was high and the complication rate was very low.
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Acknowledgements |
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We would like to thank David Hayes and Raul Chirife, who have collaborated in the redaction of this manuscript.
Conflict of interest: none declared.
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References |
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[1] Love CJ, Wilkoff FL, Byrd CL, Belott PH, Brinker JA, Fearnot NE, et al. Recommendations for extraction of chronically implanted transvenous pacing and defibrillator leads: indications, facilities, training. North American Society of Pacing and Electrophysiology Lead Extraction Conference Faculty. Pacing Clin Electrophysiol (2000) 23:544–51.[CrossRef][Medline]
[2] Byrd C, Schwartz S, Hedin N. Lead Extraction. Indications and Techniques. Cardiology Clinics (1992) 10:735–48.[Medline]
[3] Espinosa RE, Hayes DL, Vlietstra RE, Osborn MJ, McGoon MD. The Dotter Retriever and Pigtail Catheter: efficacy in extraction of chronic transvenous pacemaker leads. Pacing Clin Electrophysiol (1993) 16:2337–42.[CrossRef][Medline]
[4] Taliercio CP, Vlietstra RE, Hayes DL. Pigtail catheter for extraction of pacemaker lead (letter). J Amer Coll Cardiol (1985) 5:1020.[Web of Science][Medline]
[5] Wilkoff BL, Byrd CL, Love CJ, Hayes DL, Sellers TD, Schaerf R. Pacemaker lead extraction with the laser sheath: results of the Pacing Lead Extraction With the Excimer Sheath (PLEXES) Trial. J Am Coll Cardiol (1999) 33:1671–6.
[6] Mazzetti H, Cichero CF. Transatrial lead extraction (Abstract A296). Europace (2003) 4:B45.
[7] Bongiorni M, Soldati E, Arena G, Gherarducci G, Ratti M, Giannessi C. Transvenous removal of difficult pacing and ICD leads: a new technique through the internal jugular vein. Pacing Clin Electrophysiol (2000) 23:696.
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