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Techniques, Technology, and Innovations Section Editor: Samuel J. Asirvatham, M.D.

Femoral Approach to Lead Extraction SIVA K. MULPURU, M.D., F.H.R.S.,∗ DAVID L. HAYES, M.D., F.H.R.S.,∗ MICHAEL J. OSBORN, M.D., F.H.R.S.,∗ and SAMUEL J. ASIRVATHAM, M.D., F.H.R.S.∗ ,† From the ∗ Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota, USA; and †Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA

Femoral Extraction. Laser and radiofrequency energy–assisted lead extraction has greatly facilitated this complex procedure. Although success rates are high, in some instances alternate methods of extraction are required. In this review, we discuss techniques for femoral extraction of implanted leads and retained fragments. The major tools available, including commonly used snares and delivery tools, are discussed. We briefly describe combined internal jugular and femoral venous extraction approaches, as well as complimentary utilization of more than one technique via the femoral vein. Animated and procedural sequences are included to help the reader visualize the key components of these techniques. (J Cardiovasc Electrophysiol, Vol. pp. 1-5) femoral route, lead extraction, lead infection, mechanical extraction Introduction Expanding indications for cardiac implantable electronic devices, increasing population longevity, changes in lead design, and technology with subsequent malfunction have led to an increasing number of patients presenting for lead extraction procedures. Understanding techniques and limitations of femoral extraction is essential for a comprehensive lead management program. In this article, we attempt to outline the Mayo Clinic approach to femoral transvenous extraction. Indications for Femoral Lead Extraction Most transvenous lead extractions occur through the superior venous system utilizing the route of initial lead implantation. Using laser and mechanical tools, most leads can be extracted with higher success rates and acceptable rate of complications. However, the procedural and fluoroscopic times are longer with femoral extraction when compared with laser lead extraction.1 The femoral venous route for extraction is very helpful in certain clinical situations: This manuscript was processed by a guest editor. Dr. S. K. Mulpuru is supported by a Department of Internal Medicine Career Development Grant. S. J. Asirvatham receives no significant honoraria and is a consultant with Abiomed, Atricure, Biosense Webster, Biotronik, Boston Scientific, Medtronic, Spectranetics, St. Jude, SanofiAventis, Wolters Kluwer, and Elsevier. Other authors: No disclosures. [Correction added on 24 November 2014, after first online publication: The layout of the paper has changed due to repositioning of figures.] Address for correspondence: Samuel J. Asirvatham, M.D., F.H.R.S., 200 1st Street, Mayo Clinic, Rochester, MN 55905, USA. Fax: 507-255-2550; E-mail: [email protected] Manuscript received 19 August 2014; Revised manuscript received 9 September 2014; Accepted for publication 10 September 2014. doi: 10.1111/jce.12564

1. Inability to insert a locking stylet/need to extract lumenless leads. Tools for superior approach require tensile support from a locking stylet. Inability to support the inner lumen with a locking stylet either due to obstruction or the absence of a lumen makes the lead floppy. It is often difficult to advance the extraction tools on a floppy lead. As force may not be applied in a coaxial manner on a floppy lead, there is increased chance of vascular injury or collateral damage to surrounding structures. 2. Previously cut and abandoned leads. Often leads that are cut and abandoned retract into the proximal vasculature. They cannot be accessed for locking stylet insertion. 3. Leads implanted via femoral venous route. It is easier to insert mechanical sheaths over leads for extraction through their initial implant route. 4. Nonavailability of laser or electrosurgical extraction system. 5. Need for distal lead support to maintain superior venous access. Distal support using femoral approach is sometimes required to advance the extraction tools from a superior venous approach. Familiarity with femoral tools is invaluable in cases of lead extraction in patients with venous obstruction preventing access to the central veins. With lead dislodgement in such patients, distal support is required to regain venous access. 6. Failure of superior access laser/electrosurgical lead extraction. Direction of Forces Using Superior Access and Femoral Access Use of tools from the superior approach is associated with forces that may not be parallel to the superior vena cavainferior vena cava (SVC-IVC) long axis. Femoral approach combined with use of tools from the right internal jugular (IJ) vein forms a more coaxial force axis. Negotiating the turn from the IVC across the tricuspid valve using large caliber sheaths can be challenging on an unsupported lead from a femoral route.

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Vol. No. Figure 1. Femoral and IJ combined approach for transvenous extraction of a lead. Leads with subclavian access, but too floppy to advance sheaths from above, should have stylets removed, cut and pulled into the central vasculature using a snare or an ablation catheter. Note that the lead here is retracted into the central circulation and has fibrosis around the proximal end. A: RF energy is delivered from an ablation catheter placed from the femoral route to break the adhesions and expose the proximal end of the lead. B: A goose neck snare inserted from the right IJ is used to grab the proximal end of the lead and externalize it from the neck. C: Mechanical telescoping dilators are advanced over the lead to break up additional adhesions. D: Traction and counter traction technique is used to extract the lead from the apical myocardium. IJ = internal jugular; RF = radiofrequency.

Figure 2. Femoral coronary sinus lead extraction using needle eye snare. A: The hood of the needle eye snare is exposed to engage the lead. B: The needle is exposed to lock with the hood around the lead. C: Together they form a stable rail for application of downward force. D: The lead along with the snare is dragged inside the 16-Fr introducer sheath.

Tools Commonly Used 1. Needle eye snare. Needle eye snare (Cook Medical, Bloomington, IN, USA) has an outer 16-Fr venous access sheath. The snare is housed in a straight or curved 12-Fr inner sheath. It comes in 2 head profiles (13 and 20 mm). The larger profile snare is useful in patients with dilated atria and when larger caliber leads (high voltage) are extracted. 2. Byrd femoral work station. The Byrd femoral work station (Cook Medical) has a 16-Fr outer introducer that houses a 12-Fr catheter through which a basket catheter is introduced. Together with a tip deflecting wire, the basket provides an adequate snare for transfemoral lead removal.

3. Deflectable ablation catheter. This is particularly useful to form a hook on the lead and drag the proximal end of the lead near to the snares. Radiofrequency (RF) energy is also used for breaking adhesions in the central venous system. 4. Gooseneck snare. Gooseneck snare (eV3, Plymouth, MN, USA) has a perpendicular orientation of the snare to the body. The snare is inserted through a 6-Fr catheter and comes in several sizes; 15–25-mm diameter snares are most helpful to grasp the proximal aspect of the lead in the central veins. A 5-mm snare is useful for gasping lead fragments in the coronary sinus or inside the cardiac chambers. 5. Larger bioptome/biopsy forceps. Use of a bigger cardiac bioptome or forceps (Boston Scientific Radial Jaw Max

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Figure 3. Femoral extraction using Byrd femoral work station. A: Tip deflecting wire is used to engage the lead at the atrial level. B: The basket catheter is then exposed to engage the lead with the splines. C: The basket splines and the tip deflecting wire act synergistically to engage the lead for downward traction. D: The lead along with the basket catheter and the tip deflecting wire is then pulled into the 16Fr introducer sheath. Forward motion of the mechanical introducer sheath over the engaged lead can be helpful in leads with lots of adhesions.

Figure 4. The proximal end of the retained lead fragment in the central vasculature is grasped using a gooseneck snare and is dragged into the femoral sheath. The sheath is then advanced over the lead to provide counter traction.

Capacity 3 without needle, Natick, MA, USA) is helpful in grasping retained lead fragments. Care should be taken to close the forceps only near the lead to avoid cardiac perforation. Techniques for Femoral Lead Extraction Several steps are involved in femoral lead extraction: 1. Femoral venous access. Venous access is routinely obtained using ultrasound guidance and the sheaths are gradually upgraded to 16-Fr introducers. Meticulous attention to venous access is necessary to prevent vascular complications due to the use of large caliber sheaths. It is our practice to obtain both arterial and femoral venous access to immediately initiate cardiopulmonary bypass in the event of a vascular tear or myocardial rupture. Additional venous accesses are also obtained to insert the intracardiac ultrasound (ICE) catheter and to infuse medications or blood products. 2. Lead preparation. If femoral extraction is planned, locking stylets (EZ LLD, Spectranetics, CO, USA) that can

Figure 5. Ablation catheter along with a gooseneck snare can be used to apply downward traction on the lead to free either end. Once the end is exposed the lead is extracted through the femoral route after engagement of the tip with gooseneck snare.

be unlocked and repositioned should be used. Preferably, the stylets will be removed to make the lead floppy for femoral extraction. The proximal end of the cut lead should remain in the central vasculature. Leads with subclavian access, but too floppy to advance sheaths from above, should have stylets removed, cut and pulled into the central vasculature using a snare or an ablation catheter. Multiple venous access sites are frequently used for a successful outcome. If significant adhesions are noted near the subclavian vein/superior vena cava we occasionally use RF energy delivered through an ablation catheter to expose the lead (Fig. 1 and Video S1). The proximal end of the lead is grasped using a goose neck snare and externalized through the right IJ. Mechanical dilators along with judicious application of RF energy from an ablation catheter are used from the right IJ to break the adhesions. 3. Dragging the proximal end of the lead towards the right atrium/IVC. This can be accomplished by use of several tools. The needle eye snare and Byrd femoral work station are commonly used. The snare is often deployed from the femoral vein and the lead is engaged near the heel region in the right atrium. Fluoroscopy and ICE

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Figure 6. Femoral extraction of a retained fragment. A: A deflectable sheath is placed over the ablation catheter near the retained lead fragment. B: A bioptome is used to grab the end of the retained lead fragment. C: The goose neck snare on the shaft of the bioptome is moved forward to engage the most distal aspect of the lead fragment. D: Together as a rail traction and counter traction using the sheath is used to extract the retained fragment.

are commonly used to place the hood behind and the needle, which provides the locking mechanism, in front of the lead. The needle has to interlock with the snare to provide adequate snare support.2 Orthogonal fluoroscopic imaging is often required to engage the lead in a satisfactory manner. Once the lead is grasped using a snare downward traction is applied to pull the proximal end of the lead toward the IVC. The steps are illustrated in Figures 2 and 3 (Videos S2 and S3). Occasionally a gooseneck snare alone (Fig. 4) is used to grasp the proximal end of the lead. Use of a curved sheath facilitates proper engagement of the proximal end of the lead. If the proximal end of the lead cannot be engaged by the gooseneck snare, downward traction can be applied at the heel of the lead in the right atrium using ablation catheter and a gooseneck snare (Fig. 5). Once the end is free, the tip is engaged with snare for femoral extraction. 4. Advancement of femoral sheaths over the lead. Femoral sheaths are advanced all the way to the myocardial lead interface. Gentle traction using the snare and counter traction using the sheath is applied to free the lead tip. 5. Use of forceps and snare to extract retained/embolized lead fragments. Most leads are unsupported with a locking stylet during femoral extraction, resulting in greater chance of the lead breaking into fragments. An ablation catheter can be used to place the sheath in the vicinity of the fragment that needs to be extracted. A larger deflectable sheath is positioned near the fragment by pushing over the ablation catheter. A large bioptome forceps with a gooseneck snare loaded on the shaft is used to grasp the free end of the fragment (Fig. 6 and Video S4). The snare is moved over the bioptome and the lead fragment to provide greater support. Orthogonal plane fluoroscopy is very useful in successfully localizing and extracting these lead fragments.

Laser Lead Extraction Through the Femoral and IJ Route The working length of the laser sheath is 50 cm, which limits the use of laser sheaths in tall patients. Use of laser tools through the IJ or femoral route can be particularly useful in femoral implants or on leads within the central vasculature with lots of adhesions. Nuances of Femoral Lead Extraction Occasionally, the proximal end of the lead has excessive fibrotic tissues and cannot be drawn inside the sheath. Venous cut down at the entry site and subsequent repair may be required to successfully extract the leads. Leads with lots of adhesions in the superior veins pose a particular challenge to femoral lead extraction. Coronary sinus (CS) leads can be easily extracted using the femoral route if there are no adhesions in the main body of the CS. It is particularly challenging to extract only one out of several leads, as femoral tools can often lead to other lead dislodgement. Due to higher dislodgement risk, temporary transvenous pacing from the contralateral femoral vein or from the superior central veins is often required in patients who are dependent on pacemakers. As most leads are unsupported during femoral venous extraction, it is common to see them unravel. It is our practice to use extra support of a snare or bioptome over the lead to successfully advance the sheaths over a disrupting lead. Reimplantation of ICD/pacemaker leads is performed usually though superior approach. When vascular occlusion is present venoplasty techniques are often required for successful lead implantation. Use of hybrid technique using right IJ/femoral access sites is often required for extraction of ICD leads with significant adhesions around the defibrillation coils. Radiation exposure to the patient and the operator can be higher with femoral transvenous lead extraction.

Extraction of Infected Leads For infected leads, the initial attempt is through their route of implantation using laser/electrosurgical dissection tools. The approach is switched to femoral route if there is failure of superior approach, failure to insert a locking stylet or disruption of the lead with retained fragment. Femoral extraction skill set is invaluable in retrieving all retained fragments necessary to treat and clear blood steam infections.

Contraindications for Femoral Lead Extraction Presence of nonretrievable IVC filters and deep venous thrombosis are absolute contraindications for transvenous femoral lead extraction. Presence of IVC filters poses particular risks for manipulation of large bore sheaths required for femoral lead extraction.

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References

Complications Peripheral vascular complications as well as central venous and myocardial tears are potential major complications from a femoral lead extraction procedure. Careful attention to mechanical sheaths and wires is essential to prevent vascular injury. In the event of a venous tear, a large caliber balloon3 should be used to tamponade the tear to temporarily stabilize the patient while effective interventions are carried out. It is our practice to place a wire with extra support from the right femoral vein into the right subclavian region, which can be used to place a balloon in the event of a major complication. Routine extraction precautions including cardiac surgery back-up are always performed during femoral extractions.

1. Bordachar P, Defaye P, Peyrouse E, Boveda S, Mokrani B, Marquie C, Barandon L, Fossaert EM, Garrigue S, Reuter S, Laborderie J, Marijon E, Deharo JC, Jacon P, Kacet S, Ploux S, Deplagne A, Haissaguerre M, Clementy J, Ritter P, Klug D: Extraction of old pacemaker or cardioverter-defibrillator leads by laser sheath versus femoral approach. Circ Arrhythm Electrophysiol 2010;3:319-323. 2. Bracke FA, Dekker L, van Gelder BM: The needle’s eye snare as a primary tool for pacing lead extraction. Europace 2013;15:1007-1012. 3. Oshima K, Takahashi T, Ishikawa S, Nagashima T, Hirai K, Morishita Y: Superior vena cava rupture caused during balloon dilation for treatment of SVC syndrome due to repetitive catheter ablation—A case report. Angiology 2006;57:247-249.

Conclusions

Additional supporting information may be found in the online version of this article at the publisher’s website:

Femoral lead extraction skills are an important part of the cardiac electrophysiologist’s armamentarium for comprehensive lead management. Understanding limitations and the effective use of necessary tools is crucial for a successful outcome.

Supporting Information

Video S1. Video S2. Video S3. Video S4.

Femoral approach to lead extraction.

Laser and radiofrequency energy-assisted lead extraction has greatly facilitated this complex procedure. Although success rates are high, in some inst...
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