Lead extraction technique
The variable technical properties of both mechanical dilator sheaths
were defined in Supplementary File 1 . The TLE procedure was
performed in the Electrophysiology Laboratory under deep sedation and
local anesthesia with invasive blood pressure monitoring via femoral or
radial route, non-invasive oxygen saturation monitoring, and a
cardiothoracic surgery team standby. A thorough evaluation of pacemaker
(PM/ICD) was performed before the intervention, including the assessment
of the degree of pacemaker dependency and temporary transvenous pacing
was established if necessary. After the skin preparation, the generator
pocket was opened, and the device generator was disconnected from the
leads. The leads were separated from the scar tissue by blunt
dissection. Simple manual traction via standard stylet was initially
attempted. If manual traction was not successful, a systematic approach
using locking stylet (Liberator Universal Locking Stylet in
Evolution® group, Cook Medical) (Lead Locking Device
EZ in the TightRailTM group, Spectranetics Corp.) for
TLE. If this systematic approach was unsuccessful, mechanical dilator
sheaths were used for both atrial, right ventricular, and coronary sinus
leads.
Mechanical dilator sheath was then positioned over the targeted lead.
The operator pulls the handle of the dilator sheath, which causes
rotation of the cutting tip. The dilator sheath moves along the lead
body by cutting fibrous adhesions via the distal metal tip or blade. In
the Evolution® mechanical dilator sheath system, the
outer polymer sheath covers the distal tip while advancing over the lead
in the tracts free from adherences to protect the venous wall from
damage and when fibrous attachments met, the cutting tip uncovered from
the outer sheath. In the TightRailTM mechanical
dilator sheath system, the shielded blade dilates the fibrous
attachments by rotating 270° clockwise and 270°counterclockwise with each full trigger activation while extending the
blade just 0.5 mm. Once the fibrous attachments are cut, the outer
sheath is advanced until another area of attachment is encountered.
After the release of leads from fibrous tissue, the leads were pulled
back into the sheath and removed. In case of failure with an antegrade
approach and presence of free-floating lead remnants, a femoral or
jugular approach with Multisnare (Multi-Snare, PFM, Köln, Germany) was
used to grasp the remaining part and to complete the procedure. For
patients requiring replacement of their lead, a new lead system was
implanted through the same vein in case of lead malfunction or upgrade
to new technology. In the case of device infection, the subclavian vein
on the opposite side was used after the eradication of infectious
microorganisms according to the recommendations of the recent guidelines1. In PM-dependent patients, re-implantation was
performed in the same session if the extraction was due to
non-infectious causes. In PM-dependent patients with cardiac device
infection, a temporary PM was implanted through the contralateral
jugular vein.
During the first 48 h after the procedure, continuous non-invasive blood
pressure, oxygen saturation, and electrocardiographic monitoring were
made and echocardiographic evaluation just after the intervention and
before discharge was performed. At each follow-up visit, a thorough
device interrogation was added to the patient assessment with clinical
evaluation, electrocardiography, chest X-ray, and transthoracic
echocardiography when necessary.