Difficult dual-stage transcutaneous multiple lead extraction with loss of external silicone tube of broken lead

The extraction of three implanted (18-, 16-, and ten year-old) damaged nonfunctional leads was complicated by a lead breaking and losing its external silicone tube. The missing part of the lead was invisible on X-ray, but was visible in ECHO as a thin, corded, very mobile limp structure without metallic reflection. Incomplete lead extraction did not cease laboratory symptoms of infection. The lost silicone tube was grasped and removed via femoral approach during the subsequent transesophageal echocardiography (TEE)-guided procedure. The presented case indicates that the criterion of full radiological success is not always correct, exposes the utility of ECHO techniques for X-ray-invisible broken lead fragments, and indicates the possibility of success for such TEE-guided procedures.