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Femoral approach to lead extraction Roger A. Freedman, M.D. August 28, 2015 Component stages of lead extraction • Lead preparation • Superior approach • Femoral approach Espinoza RE, Hayes DL, Vliestra RE, et al., The Dotter retriever and pigtail catheter: Efficiency and extraction of chronic transvenous pacemaker leads. PACE 1993 Belott PH. Endocardial lead extraction: A videotape and manual. Armonk, NY: Futura Publishing, 1998 8 year old fractured Fineline lead Optimal use of outer femoral sheath 12 year old pacing system infected pocket both leads cut off at clavicle after failed attempt to cure infection D.H. D.H. D.H. D.H. D.H. D.H. D.H. D.H. D.H. Hybrid inferior-superior approach 34 year old man with repaired Tetralogy of Fallot, complete heart block, dual chamber ICD implanted 7 years ago, now with failure of RV lead. Gaining access through occluded veins 33 year old man with 3 malfunctioning defibrillator leads • 17 year old girl with idiopathic cardiomyopathy • Cardiac arrest at age 10 with prolonged hospitalization, including ECMO, and subsequent implantation of dual chamber ICD • Occasional shocks for VT/VF over the years • Presented recently with noise on both atrial and ventricular leads, resulting in inappropriate shocks Advanced techniques 14 year old ICD now infected Infected CRTD 5 leads, up to 10 years in age University of Utah Hospital Lead Extraction Risk Stratification High Risk Medium Risk Low Risk Case descriptors* leads > 20 years leads 5-20 years leads < 5 years older model dual coil ICD leads newer model ICD leads pacemaker leads only patient factors: older, poor cardiac function, multiple comorbidities average risk patient younger, healthier patient OR 5 without exception; heart room on stand-by OR 5 with rare exception no strong preference for OR 5 pump and pump team on standby pump and pump team in house pump team not necessarily in house dedicated OR nursing team immediately available OR nursing team not necessarily immediately available OR nursing team not necessarily immediately available sternotomy and thoracotomy trays ready to open sternotomy and thoracotomy trays in vicinity sternotomy and thoracotomy trays available absence of prior heart surgery Resources** *Descriptors are general guidelines; faculty cardiologist will make Risk assignment based on overall impression of the patient situation and perceived risk. **Patients requiring urgent lead extraction will sometimes have procedure performed with lower level of available resources if timeliness of extraction is most important factor for patient. 37 year old woman with complete heart block following tricuspid valve replacement 7 years earlier, now with high amplitude noise on atrial lead. Also has moderately severe TR. Femoral approach to lead extraction Roger A. Freedman, M.D. August 28, 2015 Complications of lead extraction Superior approach Femoral approach Cardiac perforation/tamponade x x Tricuspid valve damage x x SVC tear x Hematoma x x AV fistula x x Embolization of lead fragments x x Retained lead fragments x x DVT/pulmonary embolus x Dislodgement of temporary pacemaker x
