Lead extraction technique
The variable technical properties of both mechanical dilator sheaths
were defined in Supplementary File 1. The TLE procedure was performed in
the Electrophysiology Laboratory under deep sedation and local
anesthesia with invasive blood pressure monitoring via femoral or radial
route, non-invasive oxygen saturation monitoring, and a cardiothoracic
surgery team standby. A thorough evaluation of pacemaker (PM/ICD) was
performed before the intervention, including assessing the degree of
pacemaker dependency and temporary transvenous pacing was established if
necessary. After the skin preparation, the generator pocket was opened,
and the device generator was disconnected from the leads. The leads were
separated from the scar tissue by blunt dissection. Simple manual
traction via standard stylet was initially attempted. If manual traction
was not successful, a systematic approach using locking stylet
(Liberator Universal Locking Stylet in Evolution®group, Cook Medical) (Lead Locking Device EZ in the
TightRailTM group, Spectranetics Corp.) for TLE. If
this systematic approach was unsuccessful, mechanical dilator sheaths
were used for both atrial, right ventricular, and coronary sinus leads.
The mechanical dilator sheath was then positioned over the targeted
lead. The operator pulls the handle of the dilator sheath, which causes
rotation of the cutting tip. The dilator sheath moves along the lead
body by cutting fibrous adhesions via the distal metal tip or blade. In
the Evolution® mechanical dilator sheath system, the
outer polymer sheath covers the distal tip while advancing over the lead
in the tracts free from adherences to protect the venous wall from
damage and when fibrous attachments are met, the cutting tip uncovered
from the outer sheath. In the TightRailTM mechanical
dilator sheath system, the shielded blade cuts the fibrous attachments
by rotating 270° clockwise and 270° counterclockwise
with each full trigger activation while extending the blade just 0.5 mm.
Once the fibrous attachments are cut, the outer sheath is advanced until
another area of attachment is encountered. After the release of leads
from fibrous tissue, the leads were pulled back into the sheath and
removed. In case of failure with an antegrade approach and presence of
free-floating lead remnants, a femoral or jugular approach with
Multisnare (Multi-Snare, PFM, Köln, Germany) was used to grasp the
remaining part and to complete the procedure. For patients requiring
replacement of their lead, a new lead system was implanted through the
same vein in case of lead malfunction or upgrade to new technology. In
the case of device infection, the subclavian vein on the opposite side
was used after eradicating infectious microorganisms according to the
recommendations of the recent guidelines 1. In
PM-dependent patients, re-implantation was performed in the same session
if the extraction was due to non-infectious causes. In PM-dependent
patients with cardiac device infection, a temporary PM was implanted
through the contralateral jugular vein.
During the first 48 h after the procedure, continuous non-invasive blood
pressure, oxygen saturation, and electrocardiographic monitoring were
made, and echocardiographic evaluation just after the intervention and
before discharge was performed. At each follow-up visit, a particular
device interrogation was added to the patient assessment with clinical
evaluation, electrocardiography, chest X-ray, and transthoracic
echocardiography when necessary.