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Extraction and replacement of permanent pacemaker leads through occluded vessels: use of extraction sheaths as
J N Pace1, M Maquilan, S E Hessen
1Cardiac Electrophysiology Laboratory of MCP-Hahnemann School of Medicine, Allegheny University Hospitals, Hahnemann Division, Philadelphia, PA, USA.
Insights
Lead extraction through thrombosed subclavian veins or superior vena cava is feasible. This method allows new pacemaker lead replacement without accessing a new site, reducing patient morbidity.
Area of Science:
- Cardiovascular Medicine
- Interventional Cardiology
- Medical Device Technology
Background:
- Subclavian vein or superior vena cava thrombosis can complicate permanent pacemaker lead (PPL) replacement.
- Venous occlusion necessitates alternative strategies for PPL extraction and implantation.
Purpose of the Study:
- To evaluate the efficacy of using extraction sheaths as conduits through totally occluded subclavian veins or superior vena cava for PPL replacement.
- To assess the feasibility of re-implanting new PPLs ipsilateral to the venous occlusion.
Main Methods:
- Extraction of PPLs using a subclavian extraction sheath through occluded vessels.
- Utilizing the retained sheath to guide new PPL insertion.
- Adjunctive balloon venoplasty for superior vena cava dilation when necessary.
Main Results:
- Successfully extracted 210 PPLs and 2 lead fragments from 137 patients over six years.
- In three patients with totally occluded vessels, PPLs were extracted and new leads implanted ipsilaterally.
- No new access sites were required for lead replacement in these cases.
Conclusions:
- PPL extraction through thrombosed veins is a successful technique.
- This approach avoids the need for new venous access sites, potentially reducing patient morbidity.
- The procedure offers an efficient method for PPL replacement in cases of venous occlusion.
Abstract:
Patients (pts) may present for lead extraction with symptomatic or asymptomatic subclavian vein or superior vena cava thrombosis. Replacement of permanent pacemaker leads (PPLs) in these pts may be difficult and may require accessing a new site. We examined the utility of replacing PPLs through completely occluded vessels using extraction sheaths as conduits through the total occlusion. Over six years, a total of 210 atrial and/or ventricular PPLs were extracted from 137 pts. Two pts presented with angiographically documented thrombotic occlusion of the subclavian vein. One additional pt. who had presented with a superior vena cava (SVC) syndrome, had a totally occluded innominate vein and SVC occlusion. Balloon venoplasty was used as an adjunct to dilate the SVC. In all pts, after PPLs were removed via a subclavian extraction sheath through the occluded vessel, the retained sheath was used to place a guide wire, then a peel away dilating sheath, to insert new PPLs, in each case on the side of total venous occlusion. Seven PPLs and two lead fragments were extracted, and five new PPLs replaced, ipsilateral to the venous occlusion. These data show that extraction of PPLs through thrombosed veins may be performed successfully and may not require replacing the leads through a new site. This technique spares the pt the need to access the opposite subclavian vein, and it avoids an excessive number of PPLs in the subclavian vein and SVC. The procedure illustrates an efficient means to reintroduce new PPLs with the potential to reduce associated morbidity, since repeat puncture of the subclavian vein is not required. Safety of the procedure as a whole must be considered with regard to the known risks of lead extraction, some complications of which may be substantial using current techniques.
