How To Do Lead How To Do Lead ExtractionsExtractions

Joshua M. Cooper, MD, FACCJoshua M. Cooper, MD, FACCUniversity of Pennsylvania

Disclosures

• Modest Honoraria• Spectranetics• Boston Scientific• Medtronic• St. Jude• Biotronik

Before the Extraction• What is the indication?

– Infection– Lead malfunction– Upgrade or malfunction and occluded vein

• Informed consent– What are the alternatives?– Discussion with patient and family members

• Planning– Document all hardware present and implant dates– Need/timing for reimplantation? Pacer dependent?– Review TEE images – size and burden of vegetation(s)– Full complement of extraction tools– Surgical backup, anesthesia

Before the Prep

• Device interrogation– Document device settings– History of brady and tachy therapy– Underlying rhythm (need for temp wire?)

• Venogram– Planning reimplantation strategy

• Fluoroscopy of the chest– Confirm hardware present and lead locations– Motion of cardiac silhouette, lung fields

Chest Fluoroscopy

Venogram

Preparedness for Complications

Fem Arterial, Venous Access

Gen AnesthesiaCT Surgical Backup

Equipment for Bypass, Sternotomy, Pericardiocentesis,

etc. in Room Crossmatch Blood in Room Echo on Site

Entering the Pocket

Excise Around Wound

Excise Around Wound

Free the Leads - Easy

Free the Leads - Hard

Free Suture Sleeves, Remove Ties

Remove the Capsule

Cut Lead After Helix Retraction

Size the Lumen of Each Lead

Insert the Locking Stylet

Locking Stylet

Deployed stylet

Undeployed stylet

Deploy the Locking Stylet

Expanded Stylet in Conductor

Pace/Sense Conductor

Locking Stylet

Tying Onto Outer Insulation

Tying Onto Outer Insulation

Tying Onto Outer Insulation

Tying Onto Outer Insulation

Lead Components Will Slide8 components5 components

Can Also Tie to High Voltage Wires

Purse-string Suture Around Entry

Calibrate Laser Sheath

Advance Laser over Lead

Secure Locking Stylet + Ties

Watching Fluoro

Lead Binding

Factors that increase lead binding:

– Longer implant time– Younger patients– Multiple leads– ICD coils

Venous entry

SVC curve

RA

RV

RA tip

RV tip

Typical Binding Sites

Pacer Leads Bound

SVC Coil Bound

SVC Right Atrium

Right Ventricle

Tools to Extract Bound Leads

Radiofrequency Ablative Sheath

Torque/Burr Sheath

Laser Sheath

Lasing at Entry Site

Countertraction at Tip

Commonly Encountered Issues

Calcified Fibrosis

Insulation “Snowplow”

Insulation Bunching

Traction on Insulation

Use of Outer Sheath

Use of Outer Sheath

More Visible Outer Sheath

Or Can Switch the Sheath

16 Fr 14 Fr 12 Fr

Rotational Mechanical Sheath

Lead Wrap Phenomenon

Coils Can Unravel

Unraveling Lead

Unraveled Lead Removed

Hypotension• Anesthetic agents• Other medications given to lower BP• Allergic reaction/anaphylaxis• Traction on RV apex• Bleeding (femoral access, intrathoracic)• Cardiac Tamponade• Pulmonary embolism• Cardiogenic shock• Sepsis

SVC-gram

Intracardiac Echo - Vegetations

Fractured Leads

Femoral Extraction

Femoral Extraction

Elements of Successful Program• Single extractor – concentrate experience• Surgical backup – on site during procedure• Support staff – teamwork is essential• Full set of equipment – unpredictability• General anesthesia – good communication• Reasonable volume – 20-30 cases/year• Establish a routine• Preparedness for complications – always• Good implant technique• Patient education – weigh risks/benefits

Thank You!