Progressive Dissection and Mechanical Dislodgement

When advancing sheaths, it is important to use the sheath technique properly either by maintaining adequate lead tension (via the stylet or directly) or by maintaining alignment between lead and sheath to prevent damage to vessel walls. The appropriate equilibrium between pressure and traction forces is defined as lead control. Imbalance between these two forces can produce failures or complications. If excessive scar tissue or calcification prevents safe advancement of sheaths, an alternative approach must be considered. In fact. 

Independent of the energy used to free the lead, changing the approach to the lead itself may provide a possible advantage during removal. There are three approaches for transvenous lead extraction (Fig. 4.21)  

Venous entry approach, also known as the superior approach 

It seems more accurate not to use the terms superior or inferior approach and, instead, to use the terms venous entry (implant vein) approach, transfemoral vein approach, and internal transjugular approach. In fact, the term superior approach can be misleading considering that either venous entry approach or internal transjugular approach can be considered superior approaches. 

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When performing extraction procedures, either proper lead preparation and lead control or correct use of sheaths by means of counterpressure and countertraction or progressive dissection and mechanical dislodgement is usually necessary. 

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