Transjugular Approach

Lead damaged by previous unsuccessful removal attempts After an unsuccessful transvenous lead extraction (TLE), leads could be seriously damaged. Coil or insulation fracture irreversibly modifies the lead body structure, reducing the procedural success and increasing procedure complexity and complications. Intravascular leads When no part of the lead can be approached outside the vascular system, a crossover to the transfemoral or transjugular approach is mandatory. 

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. 

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

We use the internal transjugular approach (Fig. 4.28) as a first choice for free-floating leads and as an additional step for difficult leads when mechanical dilatation is ineffective or risky [8, 46]. In the presence of free-floating leads, this approach results in... 

Table 4 9Lead extraction internal transjugular approach Tools... 

How to Perform Internal Transjugular Approach if Venous Entry Approach Fails... 

Fig 5 15 Internal transjugular approach (Pisa approach). Note the straight course of the sheath over the lead, increasing efficacy and safety of adherence dilatation... 

The internal transjugular approach was successful in 59 free-floating and 187 exposed leads as crossover from the venous entry approach. In two patients, due to failure to cannulate either the right or the left internal jugular vein, we used the right subclavian vein. Using this approach, 246 leads were completely removed. The procedure was partially successful in seven leads and unsuccessful in two. In the group with exposed leads, the approach increased the success rate from 90.3% to 98.3%. 

Bongiomi MG, Soldati E, Grana M et al (1997) The internal transjugular approach a new technique for transvenous lead removal. Proceedings of Third International Symposium on Pacing Leads Sept 11-13, 1997, Vol 1. Monduzzi Editore, Italy, pp 487 90... 

Mazzetti H, Cichero CF, Tentori MC, Mascheroni O (2008) Transjugular approach for lead extraction. Europace 10(2) 156-160... 

Lead damage Coil is lengthened or any stylet cannot be inserted Dilating sheath with high-encjgy dilatation may induce venous tears or complete lead fracture Transjugular approach... 

Narrow space between clavicte and first rib Difficult sheath advancement Use oflargc sheaths often precluded Transjugular approach... 

Tight binding sites into the coronary sinus Difficult dilatation into the coronary sinus, difficult C-shaped lead course Dilators cannot be advanced into the coronary sinus dilatation cannot be advanced to the binding site Transjugular approach reverse Pisa approach dilatalion from the femoral vein... 

From Simple Traction to Internal Transjugular Approach... 

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