Table Of ContentTransvenous Lead Extraction
Maria Grazia Bongiorni
Editor
Transvenous Lead
Extraction
From Simple Traction to Internal
Transjugular Approach
Foreword by
Bruce L.Wilkoff
~
Springer
Editor
MariaGrazia Bongiorni
2nd Cardiovascular Department
AOUP,Santa Chiara University Hospital
Pisa, Italy
ISBN 978-88-470-1465-7 N 978-88-470-1466-4
DOl 10.1007/978-88-470-1466-4
SpringerMilanDordrecht Heidelberg London NewYork
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Dedicated
to allpatientsdealing with device-relatedcomplications
and
toalldoctors andnursesdevoting theirlives to carefor them
Foreword
The evolution of the management of transvenous leads has been born out of the
furnace of clinical care and the pathophysiology of lead dysfunction.
Transvenous lead extraction is only one tool in the management tool chest. At
first it wasn't much ofa tool, just a rag tag group ofideas used by a few people
trying to solve problems for patients without a solution. However, over the last
25 years and particularly with the visionary efforts of Dr. Charles Byrd and his
creativecollaboration with Cook PacemakerInc. (now CookVascularInc.), trans
venous lead extraction is not only a tool but an armory oftechniques.
There were many steps to the elevation ofthese ideas to an accepted solution,
practicedby many; tools continuouslyevolvingand acommunity developedover
years,resultspublished,passionateteachers, minorandmajorcomplications,fatal
mistakes, disparate ideas, society guidelines and all progressing due to the ongo
ing clinical need to solve problems. It is an important story and a one well told
by Dr. Bongiorni and hercolleagues. How do we teach our hard learned lessons
to the nextgeneration ofphysicians? Can we preventfuture mistakes from being
made? We must commit ourselves to recording, analysis and communication.
This book on lead extraction is unique and systematic and it is my prayer that it
is neverleft on the shelfbut studied intently and built upon endlessly.
February2011 BruceL. WilkoffMD
DirectorCardiac PacingandTachyarrhythmia Devices
DepartmentofCardiovascularMedicine
ProfessorofMedicine
ClevelandClinic LernerCollege ofMedicine
ofCaseWesternReserve University
Cleveland, Ohio
Preface
"Icando it...,Icando it...,Ican do it..."Thisaffirmationcouldberead on pins
on jackets of many participants of the Cardiac Pacing and Arrhythmology
Congress in 1989. These simple words mean that a procedure for transvenous
lead extraction was now a possibility. One participant was a dear Italian friend
of mine, a salesman, who showed me some tools for lead extraction that had
recently been produced by an American company, Cook Pacemaker, Inc., incol
laboration with agenius in thefield, Dr. Charles Byrd (thefather ofleadextrac
tion). At that time, there were three different opinions about lead extraction:
most physicians were unbelievers; many were frightened by the idea; and some
were simply curious. I was in the latter group. My interest came from the fol
lowing: (1) many patients could benefit from transvenous lead extraction (at
that time, I had a patient with lead-related endocarditis); (2) some years earlier,
my professorbegan extracting transvenous leads using empirical tools (weights,
pulleys, etc.) and, if not for his premature death, would have fully appreciated
possibility of safe transvenous lead extraction; (3) if my clever and forward
looking friend was wearing the pin being displayed at the 1989 congress, it
would have meant that, in his opinion, transvenous lead extraction was coming
ofage. So, my professional journey into transvenous lead extraction began like
a fairy tale ("Once upon a time..."), starting with a clinical need, enhanced by
intellectual curiosity, and guided by a lucky star that put the right people in the
right place at the right moment.
Since that time, there has been great progress in the field, and transvenous
lead extraction is becoming a widespread procedure in many arrhythmology
centers, with increasing indications for its performance. Consequently, physi
cians feel the needfor recommendations, indications, training, equipment, facil
ities, and other guidelines for performing transvenous lead extraction.
Subsequently, the most important scientific organizations have responded to
these needs. Many publications are now available regarding this subject, reflect
ing an obviously increasing interest in solving cardiac pacing and defibrillation
lead-related complications. This book is the result of20 years ofpersonal expe
rience in this field, and it is addressed to young cardiologists and arrhythmolo
gists, as well as to nurses and technicians, who want to learn about lead extrac
tion. Lead extraction is atrue team procedure. All participants mustknow - and
keep in mind- the interactionbetween the leadand the cardiovascularstructure,
removal indications, patient preparation, extraction tools and techniques, and
complication management in order to achieve the best possible outcomes. This
volume describes, in particular, an innovative approach to transvenous lead
extraction - the internal jugular vein approach - which is used to extract leads
otherwise difficult to remove from the venous entry site or via thefemoral vein.
x
Preface
This is the first edition ofthis book, the authors having been selected from the
Pisa School in orderto provide cohesive information while avoiding redundan
cies and contradictions. In future additions, advances in this increasingly
important field of medicine will be described. I thank the many people who
contributed to the realization ofthis book. First, sincerethanks to my great pro
fessor Carlo Contini for teaching me about arrhythmology but especially for
teaching me to care about my patients. Next, heartfelt thanks to my coworkers,
all ofwhom devoted much time to this book. A special thanks to "tireless" Dr.
Ezio Soldati for his constant support and ability to graphically reproduce ideas
and actions, and to Dr. Raffaele De Lucia for the book's arrangement.
Transvenous lead extraction demands a team effort, so thank you to my long
devoted and passionate nurses, Giampietro Ercoli, Michela Favaro, Cristina
Giannessi, and Mascia Sarti, and to Guglielmo Liva e Susy Bardelli, who
recentlyjoinedourteam. My thanks also to the University Hospital cardiac sur
geon and anesthesia team for their invaluable support, and thanks to all cardi
ologists and nurses who care for these fragile patients during preparation for
surgery and postoperatively. Finally, a sweet thought to my parents, Teresa and
Ernesto, who - through great sacrifice - made my studies and my wonderful
profession possible.
Pisa, February2011 Maria Grazia Bongiorni, MD
Contents
1 ImportanceofKnowing lead and Patient
Interaction .
Raffaele DeLucia,Giovanni Coluccia,StefanoViani and Luca Paperini
1.1 Structure,Function,and Clinical AspectsofPacemaker
and DefibrillatorLeads............................................... 1
1.1.1 PacemakerLeads...................................................... 1
1.1.2 ImplantableCardioverter- DefibrillatorLeads................... 10
1.1.3 Lead Shapes 16
1.1.4 Special Leads........................................................... 16
1.1.5 Lead-related Problemsand Extraction 17
1.1.6 What Do Lead ExtractorsWantto SeeImproved in
FutureCardiacLead Designand Materials? 18
1.2 PatientAnatomy....................................................... 22
1.2.1 Vein Anatomy.......................................................... 22
1.2.2 VenousApproaches................................................... 24
1.2.3 Critical Anatomical Regionsfor Lead Extraction................. 25
1.3 Patient-Lead Interaction............................................. 26
1.3.1 Fibrous Responseto IntravascularForeign Bodies 26
1.3.2 VascularComplications Related to Fibrous Response........... 28
References....................................................................... 30
2 From Guidelines:Definitions,Indications,Facilities,
and Outcomes ofTransvenous lead Extraction 33
RobertoVerlato,Maria Stella Baccillieri and PietroTurrini
2.1 Introduction............................................................ 33
2.2 Indicationsfor Lead Removal:Infections.......................... 33
2.3 IndicationsforLead Removal:Chronic Pain....................... 41
2.4 IndicationsforLead Removal:Venous StenosisorOcclusion.. 41
2.5 Indicationsfor Lead Removal:Functional and Nonfunctional
LeadsWithoutInfection.............................................. 42
References....................................................................... 43
XII Contents
3 Perioperative ManagementofTransvenous
Lead Extraction 47
Gianluca Solarino,Andrea Di Cori and GiulioZucchelli
3.1 Introduction............................................................ 47
3.2 PreoperativeEvaluation.............................................. 47
3.2.1 Historyand Physical Examination.................................. 47
3.2.2 Transvenous Lead Extraction Consensus 49
3.2.3 LaboratoryTests....................................................... 49
3.2.4 ChestX-Ray............................................................. 49
3.2.5 Echocardiography 50
3.2.6 PatientPreparation 50
3.2.7 Equipment.............................................................. 52
3.2.8 Staff............... .......... .......... 52
3.2.9 Intervention Room.................................................... 53
3.2.10 StandbySurgery....................................................... 53
3.3 PostoperativeManagement......................................... 53
3.3.1 AntibioticTreatment................... .......... 54
References................ .......... .......... 55
4 Tools,Techniques, and Approaches............................... 57
Luca Segreti,EzioSoldatiand Maria Grazia Bongiorni
4.1 Definitions.............................................................. 57
4.1.1 Lead Extraction Basis................................................. 57
4.2 ExtractionTools........................................................ 58
4.2.1 ImplantTools 59
4.2.2 Traction Devices....................................................... 59
4.2.3 Mechanical Sheaths................................................... 61
4.2.4 LaserSheaths 63
4.2.5 Electrosurgical Sheaths............................................... 64
4.2.6 RotatingThreaded-TipSheath...................................... 65
4.2.7 OtherExtraction Devices 65
4.2.8 FemoralTools.......................................................... 66
4.3 Techniquesfor Lead Extraction..................................... 68
4.3.1 LeadTraction........................................................... 68
4.3.2 Counterpressureand Countertraction............................. 69
4.3.3 Progressive Dissection and Mechanical Dislodgement......... 71
4.4 Approaches............................................................ 71
4.4.1 Venous EntryApproach............................. .... 72
4.4.2 Transfemoral Approach 76
4.4.3 InternalTransjugularApproach..................................... 79
References....................................................................... 80
