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#LAHRS2019
Lead extraction & replacement through
occluded vessels
Sergio L. Pinski, MD, FHRS
Cleveland Clinic Florida
West...
Severe venous stenosis or obstruction in
lead revisions or upgrades
• 25-40% in different series
• Generally asymptomatic,...
Incidence of venous obstruction in consecutive
patients at INCOR in São Paulo
de Moraes Albertini et al. Arq Bras Cardiol ...
Ipsilateral stenosis during revisions and upgrades
• Access vein, advance guidewire, dilate with progressively larger
intr...
Morani et al..Heaart Rhyhtm 2019 (in press
• We are not emotionless maximizers of
outcome
• Aggressive discounting vs. delayed
gratification
• Chagrin Factor (Alvan ...
Epstein et al. Circulation 1998;98:1517
Tarajki et al. Heart Rhyhtm 2018;15:318
Potential Drawbacks of Abandoning ICD Leads
• Lead “chatter” causing spurious shocks
• Insulation breach in pocket causing...
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 defib...
Zeiter et al. Circ Arr Electrophysiol 2016;9:e003503 Pokorney et al. Circulation 2017;136;1387
Database analyses do not su...
Alqaravi et al. JACC Clin Electrophysiol 2019;5:1059
Contralateral venous access
• Straighforward
• Venous access further compromised
• If unnecessary leads are present, they ...
Venoplasty
• Requires especial but widely avaiable equipment
• Can be performed safely in the EP lab
• CTS back is not nec...
Lead extraction
• Requires especial and more expensive equipment
• Better performed in hybrid room or OR?
• CTS back is ne...
Pre
Removed
RV lead
Post
New LV
lead
Courtesy Dr. Rob Schaller
Courtesy Dr. Rob Schaller
Courtesy Dr. Rob Schaller
Courtesy Dr. Rob Schaller
Need to snare lead from below when it becomes loose
before crossing the occlusion with the sheath
Courtesy Dr. Rob Schaller
Courtesy Dr. Rob Schaller
Courtesy Dr. Rob Schaller
Can pass a guidewire?
Dilatation/venoplasty Unnecessary lead that would not
be very difficult/risky to extract?
Usable oth...
Lead extraction and replacement through occluded vessels
Lead extraction and replacement through occluded vessels
Lead extraction and replacement through occluded vessels
Lead extraction and replacement through occluded vessels
Lead extraction and replacement through occluded vessels
Lead extraction and replacement through occluded vessels
Lead extraction and replacement through occluded vessels
Lead extraction and replacement through occluded vessels
Lead extraction and replacement through occluded vessels
Lead extraction and replacement through occluded vessels
Lead extraction and replacement through occluded vessels
Lead extraction and replacement through occluded vessels
Lead extraction and replacement through occluded vessels
Lead extraction and replacement through occluded vessels
Lead extraction and replacement through occluded vessels
Lead extraction and replacement through occluded vessels
Lead extraction and replacement through occluded vessels
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Presented at LAHRS 2nd Scientific Sessions, Guadalajara, September 2019

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Lead extraction and replacement through occluded vessels

  1. 1. #LAHRS2019 Lead extraction & replacement through occluded vessels Sergio L. Pinski, MD, FHRS Cleveland Clinic Florida Weston, Florida, USA @SergioPinski
  2. 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. 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. 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
  5. 5. Morani et al..Heaart Rhyhtm 2019 (in press
  6. 6. • We are not emotionless maximizers of outcome • Aggressive discounting vs. delayed gratification • Chagrin Factor (Alvan Feinstein)
  7. 7. Epstein et al. Circulation 1998;98:1517 Tarajki et al. Heart Rhyhtm 2018;15:318
  8. 8. 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”
  9. 9. 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
  10. 10. 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
  11. 11. Alqaravi et al. JACC Clin Electrophysiol 2019;5:1059
  12. 12. 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.
  13. 13. 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.
  14. 14. 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
  15. 15. Pre Removed RV lead Post New LV lead
  16. 16. Courtesy Dr. Rob Schaller
  17. 17. Courtesy Dr. Rob Schaller
  18. 18. Courtesy Dr. Rob Schaller
  19. 19. Courtesy Dr. Rob Schaller
  20. 20. Need to snare lead from below when it becomes loose before crossing the occlusion with the sheath Courtesy Dr. Rob Schaller
  21. 21. Courtesy Dr. Rob Schaller
  22. 22. Courtesy Dr. Rob Schaller
  23. 23. 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

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

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