Laser Sheaths

I cm from the heart wall. An outer sheath is used as a workstation and for counterpressure and countertraction. The lead is then removed from the heart wall using countertraction. 

II sheath, which has improved mechanical properties enhancing advancement over the lead, has recently been developed as the second-generation laser sheath. In comparison with the previous model, the sheath is 10 cm longer, and its distal 

10-cm segment is more flexible. Moreover, the 15° bevel tip makes it easier to pass the sheath over the acute vascular and lead angles, and the sheath composition provides either an inner lubricious coating or an increased body torsional strength. 

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Bakir I, La Meir M, Degrieck I et al (2005) Contralateral replacement of pacemaker and leads following laser sheath extraction and concomitant stenting for superior vena cava syndrome. Pacing Clin Electrophysiol 28(10) 1131-1134... 

Laser sheaths sheaths that employ fiberoptics... 

After binding site is cleared, laser sheath i advanced to next binding site... 

Tears in the venous wall of the innominate vein and SVC have been reported with the Excimer sheath [34-39], as has cardiac tamponade due to lasing into the heart [22]. The inability of the laser technique to overcome calcified scar tissue and to perform dilation near the tip of the lead are major limitations [19]. Laser sheaths have a larger diameter compared with mechanical sheaths, and advancing them through the costoclavicular space is often difficult. Another limitation is the consistently higher cost of equipment and sheaths. Despite these disadvantages, this technique spreads rapidly and is today the most commonly used technique in the USA [9, 11]. Whereas earlier studies addressed the efficacy and safety of the initial laser sheath models [36], the recent Lead Extraction in the Contemporary Setting (LExICon) Study [40]... 

Epstein LM et al (1999) Initial experience with larger laser sheaths for the removal of transvenous pacemaker and implantable defibrillator leads. Circulation 100(5) 516-525... 

Wilkoff BL et al (1999) Pacemaker lead extraction with the laser sheath results of the pacing lead extraction with the excimer sheath (PLEXES) trial. J Am Coll Cardiol 33(6) 1671-1676... 

Byrd CL et al (2002) Clinical study of the laser sheath for lead extraction the total experience in the United States. Pacing Clin Electrophysiol 25(5) 804-808... 

After this initial report, results of the multicenter experience were released in 2002 [22]. From October 1995 to December 1999, 1,684 patients (2,561 pacing and defibrillator leads) were treated with laser sheaths at 89 sites in the USA. Complete removal was achieved in 90% of leads, 3% were partially removed, and 7% were failures. The large number of procedures and increasing number of centers using the procedure reduced the difference in success rate in comparison with mechanical dilatation. Major perioperative complications (tamponade, hemothorax, pulmonary embolism, lead migration, death) were observed in 1.9% of patients with in-hospital death in 13 (0.8%). Minor... 

FLEXES Pacemaker Lead Extraction with the Laser Sheath, PLESSE Pacing Lead Extraction Surveillance Study in Europe... 

Bordachar P, Defaye P, Peyrouse E et al (2010) Extraction of old pacemaker or cardioverter defibrillator leads by laser sheath versus femoral approach. Circ Arrhythm Electrophysiol 3(4) 319-323... 

Worldwide experiences are reported in the literature, and the centers with the highest number of patients undergoing lead extraction provide the means for a direct and complete analysis of this issue. The Pacing Lead Extraction with the Excimer Sheath (FLEXES) trial first showed that the addition of a laser sheath significantly... 

Bracke FA, Meijer A, Van Gelder B (1998) Learning curve characteristics of pacing lead extraction with a laser sheath. Pacing Clin Electrophysiol 21 2309-2313... 

The tools of endocardial lead extraction have evolved from the crude pulley-and-weight system of Buck s traction to modem excimer laser sheaths. Today, there is a complete armamentarium of tools designed to make endocardial lead extraction safe and expeditious. Each tool has its place and can play an integral part in any challenging lead extraction case. 

Powered sheaths have replaced the telescoping metal, polypropylene, and Teflon sheaths. There are now two powered sheaths available for clinical use for lead extraction. Powered sheaths use an energy source to cut through and vaporize the encapsulating fibrous scar that has grown around the endocardial lead. The first commercially available and FDA approved power sheath is the Spectranetics excimer laser sheath. The second and more recently available is the Cook Vascular Electrosurgical Dissection Sheath. The powered sheaths are available in multiple sizes between 12 and 16 French (Fig. 6.9). The power sheaths are also complemented with outer Teflon sheaths for counterpressure and countertraction. 

The excimer laser now has a lead extraction application (47-54). This laser, which once held much promise in angioplasty, is now used in endocardial lead extraction. Byrd, working with Spectranetics, developed a laser sheath to assist lead removal. The sheath was designed to work in conjunction with the Spectranetics CVX-300 excimer laser system (Fig. 6.38). The laser sheath consists of circumferentially arranged laser fiber bundles (Fig. 6.39). 

Eig. 6.39 (a) The excimer laser sheath, (b) The tip of the laser sheath and cross-sectional view of the laser sheath demonstrating the circumferentially arranged fiber bundles. 

Fig. 6J9 (continued) (c) Illustration of the laser sheath passing over the lead and approaching an area of encapsulating fibrous scar. Note the laser sheath is advancing through an outer Teflon sheath. The tip of the laser sheath is beveled 15°. The LLD locking stylet is seen within the lead lumen. 

The predominant extraction approach was via the implant vein in all three periods. The major method of extraction via the superior approach was by use of the locking stylets and sheaths together. In the third period, during which several centers participated in the clinical trial for the excimer laser sheath, laser sheaths were used in combination with locking stylets and mechanical sheaths for 30% of the leads. 

Al-Khadra AS, Wilkoff Bl, Byrd CL, et al. Extraction of nonthoracotomy defibrillator leads using the Spectranetics LASER sheath the US experience. (Abstract) PACE 1998 21 889. 

Rrishnan S, Epstein L. Initial experience with a laser sheath to extract chronic transvenous implantable cardioverter-defibrillator leads. Am J Cardiol 1998 82 1293-1295. 

Reiser C, Taylor K, Lippincott R. Large laser sheaths for pacing and defibrillator lead removal. Lasers Surg Med 1998 22 42-45. 

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