Transfemoral Approach

A transfemoral approach (Fig. 4.25) using a workstation provided with different remote control tools was introduced in the early 1990s, the same time as mechanical dilatation techniques were introduced [26]. The transfemoral approach is versatile and is used in percutaneous retrieval of car- 

The transfemoral approach is adopted in many centers as a primary approach when free-floating leads are involved and as an alternative approach in case of failed primary approach through the implant vein [23, 43-45]. Some techniques using the transfemoral approach allow grasping and removal of exposed or intravascular leads, fragments of 

An alternative to the basket and tip-deflecting wire is the Needle s Eye snare (Fig. 4.27). This extraction tool can be inserted through and used in conjunction with the Byrd Workstation [23]. This, too, is a transfemoral grasping tool that forms a basket snare around the lead body. It is delivered to the vicinity of the lead through a long, flexible, 12-F cannula placed coaxially within a larger outer cannula that has a hemostasis valve at its proximal end. The flush port is continuous with the snare s innermost lumen. The Needle s Eye snare is designed to 

Whereas free-floating leads with detached tips 

26a-d Removal of lead using the Byrd Workstation, tip deflecting wire and basket 

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In addition to the previously described tools, there are other tools that can be used following the transfemoral approaches to lead extraction. They are classified depending on their use in catheters and snares. Usually, these tools can be used either in one- or two-step approaches (described later in under Femoral Approach ). Briefly, when a lead s free proximal end is accessible, the one-step femoral approach is adopted. Otherwise, a two-step approach must be used, with the former step used to create a loop around the lead to pull the proximal end of the lead in the I VC. 

Transfemoral approach, also known as the inferior approach... 

Most operators begin with a venous entry approach using the implant vein and switch to a transfemoral approach if necessary [30]. Moreover, when leads are broken or free floating, the transfemoral approach is historically performed. Different venous approaches using the mechanical dilatation tech-... 

Fig 4 21 Approaches for transvenous lead extraction venous entry approach using the implant vein (a), transfemoral approach (b), internal transjugular approach (c)... 

Table 4 8 Lead extraction transfemoral approach Tools...

During the process of adherence dilatation and dissection, the sheath may be torn or become buckled if this happens, it should be replaced by a new one. In some cases, when a piece of fibrous tissue remains around the lead tip, the lead does not enter into the sheath and stops at level of the SVC or innominate or subclavian vein. In these cases, to complete the procedure, it is sufficient to insert telescopically a larger sheath to include the tip in other cases, a transfemoral approach may be necessary to complete the procedure and remove the lead through the femoral vein. When, despite the use of a larger sheath, lead-tip detachment is not obtained or sheath rotation or advancement is dif-... 

Fig 5.8 Temporal-sequence fluoroscopic images showing (a) the atrial lead being grasped by a tip-deflecting wire inserted through a transfemoral approach, (b) proximal end of the lead now intravascular... 

Transfemoral approach with a tip-deflecting wire or steerable catheter in order to catch the lead in the region where the lead is free (in the right atrium if the lead slips through the adher-ences in the innominate vein if the lead does not slip into the adherences) and to make the proximal end intravascular and free floating. It is important to catch the lead as near as possible to the proximal end, where only insulation is present (Fig. 5.11). 

Fig 5 11 Fluoroscopic images showing the next two steps in the case in the Figure 5.8 (a) atrial-lead-grasping maneuver using a tip-deflecting wire inserted via the transfemoral approach (b) proximal end of the lead, now intravascular, is then caught by a lasso... 

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... 

Fig 10 4 Posteroanterior chest X-ray of a patient who underwent an unsuccessful attempt at lead removal, (a) Note the two pacing-lead pieces embedded into a binding site at the superior vena cava level, (b) The fragmented leads were removed by catching their distal end with a lasso inserted through the transfemoral approach... 

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