Presented at LAHRS 2nd Scientific Sessions, Guadalajara, September 2019

1. #LAHRS2019
Lead extraction & replacement through
occluded vessels
Sergio L. Pinski, MD, FHRS
Cleveland Clinic Florida
Weston, Florida, USA
@SergioPinski

2. Severe venous stenosis or obstruction in
lead revisions or upgrades
• 25-40% in different series
• Generally asymptomatic, gradual and collaterals.
• Can be suspected with good predictive value looking at superficial
collateral circulation on top of the pocket.
• Venous ultrasound
• Preoperative DSA venogram or chest CT with contrast
• Venogram day of procedure before opening of the pocket

3. Incidence of venous obstruction in consecutive
patients at INCOR in São Paulo
de Moraes Albertini et al. Arq Bras Cardiol 2018;111:686

4. Ipsilateral stenosis during revisions and upgrades
• Access vein, advance guidewire, dilate with progressively larger
introducers. Consider snaring the guidewire from below for more “rail”
• Access the vein proximally to the stenosed or occluded segment
• Access internal jugular vein.
• Advance guidewire, perform venoplasty
• Extract one lead (especially if unnecessary) reclaim access through
extraction sheath
• Contralateral access, complete new system or tunnel leads
• Other approach: transfemoral, epicardial, SQ ICD

10. Morani et al..Heaart Rhyhtm 2019 (in press

11. • We are not emotionless maximizers of
outcome
• Aggressive discounting vs. delayed
gratification
• Chagrin Factor (Alvan Feinstein)

12. Epstein et al. Circulation 1998;98:1517
Tarajki et al. Heart Rhyhtm 2018;15:318

13. Potential Drawbacks of Abandoning ICD Leads
• Lead “chatter” causing spurious shocks
• Insulation breach in pocket causing electrical shorting during high-
voltage shock and generator damage
• Large diameter could promote venous obstruction (SVC syndrome) or
tricuspid regurgitation
• Extraction will be very difficult if needed down the road
• “A lead will never be easier to extract than is today”

14. Rules of thumb
• No more than 4 leads in a single subclavian vein
• No more than 5 leads in the SVC
• No more than 2 defibrillation leads

16. Zeiter et al. Circ Arr Electrophysiol 2016;9:e003503 Pokorney et al. Circulation 2017;136;1387
Database analyses do not suggest an advantage of
extracting vs capping ICD leads in Medicare beneficiaries

17. Alqaravi et al. JACC Clin Electrophysiol 2019;5:1059

18. Contralateral venous access
• Straighforward
• Venous access further compromised
• If unnecessary leads are present, they are not removed. Lead
“burden” is increased.
• ? Higher incidence of lead dislodgement (stress relieving loop)
• Avoid extenders. Use long leads.

21. Venoplasty
• Requires especial but widely avaiable equipment
• Can be performed safely in the EP lab
• CTS back is not necessary
• In experienced hands, high success rates (>90 %)
• Contralateral venous access is preserved
• If unnecessary leads are present, they are not removed. Lead
“burden” is increased.

27. Lead extraction
• Requires especial and more expensive equipment
• Better performed in hybrid room or OR?
• CTS back is necessary
• In experienced hands, high success rates (>90%)
• But riskier (1-2%)
• May close collaterals resulting in acute arm edema
• Could damage other leads (rare with laser sheath)
• Contralateral venous access is preserved
• Unnecessary leads are removed.
• If no abandoned leads are left, helps to preserve MRI compatibility

28. Pre
Removed
RV lead
Post
New LV
lead

29. Courtesy Dr. Rob Schaller

30. Courtesy Dr. Rob Schaller

31. Courtesy Dr. Rob Schaller

32. Courtesy Dr. Rob Schaller

33. Need to snare lead from below when it becomes loose
before crossing the occlusion with the sheath
Courtesy Dr. Rob Schaller

34. Courtesy Dr. Rob Schaller

35. Courtesy Dr. Rob Schaller

40. Can pass a guidewire?
Dilatation/venoplasty Unnecessary lead that would not
be very difficult/risky to extract?
Usable other side?
Implant from other
side (and tunnel)
Necessary but not
crucial lead? (ie, atrial,
SC defibrillation in not
dependent)
Extract with sheath to
regain access
Think outside
the box
A common sense approach to venous obstruction for the everyday
implanter
Extract with sheath to
regain access