Case Report
A 49-year-old male patient had
undergone a dual-chamber pacemaker (Accent MRI; Abbott, Chicago, IL,
USA) implantation for intermittent complete atrioventricular block 9
years previously. He provided written informed consent to personal data
treatment. He was referred to our
hospital for TLE and replacement of the right ventricular (RV) lead
(Tendril MRI LPA1200M/52cm; Abbott) after multiple presyncope episodes
owing to electrical artifact on the RV lead (Figure 1A). There were no
remarkable findings on a chest X-ray (Figure 1B). A pacemaker check at
our hospital showed multiple episodes of electrical artifacts in the RV
lead, but no issues with the right atrial (RA) lead (Tendril MRI
LPA1200M/46cm; Abbott). The patient was scheduled for TLE, replacement
of the RV lead, and pacemaker generator exchange.
We performed TLE with cardiac surgery backup in a hybrid operating room
under general anesthesia using a combined superior and femoral approach
called “Tandem” to achieve co-axial alignment of the powered sheath
with the RV lead. Initially, we freed the device from its left
prepectoral pocket, and dissected the RV lead free in the superior
approach. We then inserted a locking stylet (Liberator Beacon Tip; Cook
Medical Inc.), which could reach the lead tip, but the fixation helix of
the RV lead could not be unscrewed. A locking stylet was then deployed
and secured on the lead using a one-tie accessory (Cook Medical Inc.).
After confirming the patency of the subclavian vein, we performed
subclavian vein puncture more distally before the lead extraction
procedure to establish a new access route for the new RV lead.
Simultaneously, we initiated the femoral approach using the Wire TRUST
technique. The process of the Wire TRUST technique was as follows.
First, A 14Fr sheath (Check-Flo Performer; Cook Medical Inc.) was
inserted into the right common femoral vein. A 4Fr pigtail catheter
(Terumo, Tokyo, Japan) was inserted into the 14Fr sheath and advanced in
the RA by hooking the ventricular lead under multidirectional
fluoroscopic guidance (Figure 2A). A 0.014-inch guidewire (Hi-Troque
Command 300 cm; Abbott Vascular) was then inserted and advanced through
the pigtail catheter. After crossing the ventricular lead, the
0.014-inch guidewire was further advanced to the inferior vena cava
(IVC). A 6Fr snare catheter with a 35-mm-diameter loop (ONE
Snare; Merit Medical) was inserted into the 14Fr
sheath side-by-side with the pigtail catheter and then advanced into the
IVC and opened in advance (Figure 2B). The distal side of the 0.014-inch
guidewire was passed through the ONE Snare and withdrawn into the 14Fr
femoral sheath for wire externalization (Figure 2C). After the removal
of the pigtail catheter and 6Fr snare catheter, we passed both ends of
the 0.014-inch guidewire through the snare outside of the body. The
snare was then closed and reinserted into the 14Fr sheath (Figure 2D).
After the snare catheter emerged from the tip of the sheath, the snare
in the expanded position was advanced up to the vicinity of the lead
(Figure 2E). Simultaneously advancing and closing the snare while
tensioning the 0.014-inch guidewire after externalization securely held
the lead (Figure 2F).
The RV lead was then extracted using a 14Fr GlideLight laser sheath
(Philips, Amsterdam, The Netherlands) after firmly grasping it with the
Wire TRUST technique (Figure 2G, H). A new RV lead (Tendril
STS/2088TC-58cm; Abbott) was inserted using a newly established
subclavian vein puncture site (Figure 2I). This lead was not removed
because there were no issues with the data for the RA lead compared with
before the procedure. The extracted lead showed fibrotic tissue with
calcification (Figure 2J). A new generator (Assurity DR MRI; Abbott) was
implanted, and the procedure was completed without any complications.