Femoral vein lead extraction techniques

From December 1988 to April 1994, the extraction of 2,195 intravascular pacing leads from 1,299 patients was attempted at 193 centers. Leads had been implanted for 0.2 months to 24 years (mean 56 months). Indications were infection (54%, including 10% septicemia), removal of nonfunctional or incompatible leads (40%), and other causes (6%). Extraction was attempted via the implant vein using locking stylets and dilator sheaths via the femoral vein using snares, retrieval baskets, and sheaths or using both approaches. With this technique, 86.8% of leads were completely removed, 7.5% were partially removed, and 5.7% were not removed [16]. 

Jarwe et al. reported experience with the transfemoral approach [38]. In 1999, the authors published the results of extraction using a snare (lasso) via the femoral vein as a first approach in 116 leads and an alternate approach - after extraction from the original site of implantation had failed -in another 12 leads. Mean implant time was 62 months. Of the 128 leads, 122 (95%) were completely removed, two (2%) were partially extracted (distal electrode remaining attached to the myocardium), and four (3%) could not be removed. Complications occurred in four cases. In the same period, they reported their experience with ICD lead removal using the same technique [39]. In 11 patients, they removed five leads using... 

There are three fundamental anatomic approaches for lead extraction (23,24,37). The first is retrieval by the implant vein, frequently called the superior approach. This approach can include simple traction. Buck s traction, the use of locking stylets with traction, or the use of locking stylets with countertraction sheaths. The second approach is transfemoial, frequently called the inferior approach. This approach may involve several distinct techniques. When this involves entangling a lead with a pigtail catheter, the catheter is passed from below. When free open ends present themselves, a wire-loop system may be used with traction. Both the Dotter retriever and Dormia basket may also be applied for traction from below. Finally, the lead to be removed may be extracted by the Byrd Femoral Work Station with the use of a combination of snares and wire loops. The third and final approach is retrieval of leads by a limited thoracotomy. 

Extraction using the femoral vein is a much more versatile approach, hi reality, extraction via the femoral vein may be used as a primary approach and is the procedure of choice for extraction of broken or cut leads that are free-floating in the venous system, heart, or pulmonary artery. It is also the technique of choice in situations of grossly contaminated venous entry sites where there is risk of pushing contaminated debris into the central circulation by the superior approach. There are a variety of techniques for extracting leads by the femoral vein approach (Table 6.6). 

A limited thoracotomy should be considered if both the superior (implant vein) and inferior (femoral) approaches fail to extract the lead. In 1985, Byrd and associates described a limited surgical approach for extracting chronic pacing leads that were unsuccessfully removed by transvenous techniques (46). A limited thoracotomy with low morbidity has been developed that totally avoids an extensive thoracotomy, as well as median sternotomy. This approach generally has been used as a primary approach in patients with uninfected lead systems that require removal. The transatrial approach allows for removal of leads that are inaccessible by the superior vena cava or inferior vena cava approach. This approach also affords ease of replacement of endocardial lead systems by the same technique. This is why it is most amenable to patients who are not infected. The transatrial approach with a limited thoracotomy has also been used for replacement of endocardial lead systems when all available veins have been obliterated after a superior vena caval or inferior vena caval extraction procedure. 

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