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Introduction

The application of implantable cardioverter-

defibrillators (ICDs) for prevent of sudden cardiac

death is well established. With the increase in

patients with electronic devices and leads, removal

procedures are also increasing steadily.

Lead extraction involving simple traction and

countertraction techniques that are performed by

using a locking stylet and polypropylene dilator

sheath is the only method available in Korea.

However, this conventional method cannot be

performed in some complicated cases. In such

cases, another extraction instrument is inevitably

required.

We report the case of a patient with an infection

at the pocket site who had undergone lead

extraction with a basket snare via the femoral

approach.

Case Report

A 27-year-old man visited our division for the

evaluation of a color changes at the ICD pocket site.

He had received ICD implantation 13 months

before. An ICD (single chamber, dual coils; Virtuoso

DRó D164AWG; Medtronic Inc., Minneapolis, MN,

Successful extraction of animplantable cardioverter-defibrillatorlead in a patient with pocket infectionvia the femoral approach with abasket snare

ABSTRACTA 27-year-old man was admitted to our institution with implantable cardioverter-defibrillator (ICD) pocket

infection. The ICD (single chamber, dual shock coils) was implanted for the prevention of aborted sudden

cardiac death due to idiopathic ventricular fibrillation. Because we could not use locking stylet and counter-

traction manuever, baseket snare with metal wire should be hanged at the maximal distal site of lead. With

repeated simple traction, the ICD lead was completely removed. The femoral approach with snares and kits is

not the first choice of lead extraction. It is indicated in cases of lead breakage, cases where other techniques

fail to extract leads from the superior veins, and cases where application of excessive force to the mechanical

sheaths is to be avoided. Therefore, we recommend the femoral approach with basket snare should be used

in some selective cases.

Key words: ·device removal · implantable-cardioverter defibrillator · infection

Received: May 26, 2012Revision Received: July 05, 2012Accepted: August 15, 2012Correspondence: Jin-Bae Kim, MD, PhD, Cardiology Division, Departmentof Internal Medicine, Kyung Hee University College of Medicine, Seoul,Korea 130-702Tel: 82-2-958-8200, Fax: 82-2-968-1848, E-mail: jinbbai@khu.ac.kr

Jin-Bae Kim, MD, PhD.Cardiology Division, Department of Internal Medicine, Kyung Hee University College of Medicine, Seoul, Korea

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USA) was implanted for the treatment of aborted

sudden cardiac death due to idiopathic ventricular

fibrillation. His body temperature, pulse rate, and

blood pressure were recorded 36.5ΔC, 78 beats/min,

and 120/80 mmHg, respectively. On physical

examination, showed that the ICD pocket site was

pale red and had an abscess (size, 4ø5 cm)

however, no tenderness was observed (Figures 1A,

1B). The laboratory tests included, biochemical

profile, cardiac enzyme evaluation, and a hemoglobin

was also obtained. The results showed that the

levels of creatine kinase MB isoenzyme, creatine

kinase, and creatine kinase isoenzyme index were

1.4 ng/mL (reference range, 0.0~6.9 ng/mL), 43

U/L (reference range, 40~150 U/L), and 3.2%

(reference range, 0.0~3.5%), respectively. The

patient's troponin I level was found to be elevated to

0.02 ng/mL (reference range, 0.00~0.04 ng/mL),

and the high-sensitivity C-reactive protein level

was 1.5 mg/dL. The results of other laboratory tests

were within the reference limits. After identifying

the site of pocket infection, the ICD can and pocket

site debris were removed. The ICD lead was

extracted with surgical back-up team 3 days after

the generator was removed. The ICD lead (Sprint

Quattroó 6944; Medtronic Inc.) was a tined lead,

and the diameter of the lead tip and shaft

(comprising the shock coil) was 2.7 mm. We

performed lead extraction (Figure 2A, 2B) via the

femoral approach combined with the lead-vein

entry-site approach by using a basket snare.

Simple traction applied via the lead vein entry site

caused the lead coil to stretch. A basket snare with

a metal wire was hung at the maximal distal site of

lead. Furthermore, countertraction could not be

used. To separate the ICD lead from the apex of the

right ventricle (RV). only repeated traction force

was applied to the basket snare. After applying

simple traction with a basket snare for an extended

period, the ICD lead was successfully removed

without any evidence of lead fragments remaining

in the RV. The extracted lead was found to be

encapsulated with fibrous tissue and had an

elongated shock coil (Figure 3). Monitoring of

hemodynamic parameters and fluoroscopicexamination

of the cardiac silhouette were performed regulary

Figure 1. Patient's photograph showing the color change at the site of pocket infection and abscess formation (A, B).

A B

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Figure 2. Basket snare (A) and a reversible loop formed by the basket snare around the lead (B).

A B

Figure 3. Extracted lead surrounded by the encapsulating fibrous tissue.

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during the procedure. No evidence of major

complications such as hemo-pericardium,

hemothorax, or myocardial inversion was observed.

We planned the insertion of a new lead after the

success of ICD lead extraction was confirmed.

However, the patient and his guardians did not

consent to the procedure. Therefore, we discharged

the patient after complete treatment of the

infection and achievement of wound closure.

Discussion

Transvenous pectoral implantation of an active

can has become the standard technique for ICD

placement. The complication rates involving leads

have been increasing with the increase in the

number of ICD and cardiac resynchronization

therapy defibrillator (CRT-D) implantations. Lead

extraction is a high-risk procedure, with a

morbidity rate of 1.4~2.5%.1, 2 ICD lead extraction is

known to have a higher complication rate than

pacemaker lead extraction.3 Segments of chronically

implanted leads are usually encapsulated with

fibrous tissue that adheres to the major veins or

ventricular wall. Lead extraction techniques are

designed to free the lead from the encapsulating

fibrous tissue or to free the encapsulating tissue

from the vein or the heart wall. Major complications

such as hemopericardium, hemothorax, and death

may occur during the dissection of fibrous tissue

around implanted leads.2 To increase the success

rate of procedures involving complete lead removal,

various extraction techniques have been used,

including direct traction using rotational forces;4

traction with a locking stylet; and countertraction

using a dilating sheath, femoral workstation, laser

sheath, or electrosurgical sheath. Traction and

countertraction performed using a locking stylet

and dilating sheath is a conventional technique

used in pacemaker lead extraction and ICD lead

extraction techinques5 and has been proven to be

effective and safe in clinical trials. However, this

conventional kit was not available in Korea when

we performed this procedure. Therefore, we

performed lead extraction via the femoral approach

with a basket snare. Various snares have been used

in lead extraction procedures. A snare has to have

enough tensile strength to support the forces

required for the lead extraction procedure and

provide force for aligning the target lead in

different directions. Although basket snares were

not developed for lead extraction, they can be used

to form a reversible loop around the target lead.

Forming a reversible loop is a complicated

technique that involves a few specialized kits and

procedures that require repeated practice to

achieve perfection.6 By using a basket snare with a

metal wire, we easily created a reversible loop

around the ICD lead, thereby providing more

efficient traction to the lead. Currently, the femoral

approach involving snares and kits is not

considered a first-line procedure for lead extraction.

It is indicated in cases of lead breakage, cases

where other techniques fail to extract leads from

the superior veins, and cases where application of

excessive force to the mechanical sheaths is to be

avoided. Therefore, we recommend that lead

extraction be performed via the femoral approach

using basket snares only in select cases.

References

1. Smith HJ, Fearnot NE, Byrd CL, Wilkoff BL, Love CJ, Sellers TD.Five-years experience with intravascular lead extraction. U.S.Lead Extraction Database. Pacing Clin Electrophysiol.1994;17:2016-2020.

2. Byrd CL, Wilkoff BL, Love CJ, Sellers TD, Turk KT, Reeves R,Young R, Crevey B, Kutalek SP, Freedman R, Friedman R,Trantham J, Watts M, Schutzman J, Oren J, Wilson J, Gold F,Fearnot NE, Van Zandt HJ. Intravascular extraction of problematicor infected permanent pacemaker leads: 1994-1996. U.S.Extraction Database, MED Institute. Pacing Clin Electrophysiol.

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1999;22:1348-1357.3. Hauser RG, Katsiyiannis WT, Gornick CC, Almquist AK, Kallinen

LM. Deaths and cardiovascular injuries due to device-assistedimplantable cardioverter-defibrillator and pacemaker leadextraction. Europace. 2010;12:395-401.

4. Rosenheck S, Weiss A, Leibowitz D, Sharon Z. Noninstrumentalpacemaker and defibrillator lead removal: the importance of therotation forces. Pacing Clin Electrophysiol. 2002;25:1029-1036.

5. Alt E, Neuzner J, Binner L, Göhl K, Res JC, Knabe UH, ZehenderM, Reinhardt J. Three-year experience with a stylet for leadextraction: a multicenter study. Pacing Clin Electrophysiol.1996;19:18-25.

6. Klug D, Jarwé M, Messaoudéne SA, Kouakam C, Marquié C, GayA, Lacroix D, Kacet S. Pacemaker lead extraction with theneedle's eye snare for countertraction via a femoral approach.Pacing Clin Electrophysiol. 2002;25:1023-1028.