The Benefits of Femoral Access in Patients Undergoing Transvenous Lead Extraction via Subclavian Route

Objectives: We undertook this study to determine whether additional use of prophylactic arterial and venous femoral sheaths in patients undergoing transvenous lead extraction (TLE) via subclavian route, might be useful to handle any possible complication and avoid further fatal situation, to achieve complete procedural success.

Methods: From January 2012 to August 2017, transvenous lead extraction (TLE) of 412 leads was performed in 207 patients. Indications for TLE were; infections 67.2%, lead malfunctions 18.8% or other indications 14.0%. All cases were performed in hybrid suite under general anesthesia by the above-mentioned heart-team with the aid of fluoroscopy, transesophageal echocardiography (TEE) including 3D TEE guiding and intra-arterial blood pressure monitoring. Patients were prepared for emergent sternotomy with cardiopulmonary bypass (CPB) standby. We started every procedure by placing one arterial and two venous 6F femoral sheaths at the groin site for safety reasons (temporary pacing, occlusion balloon or CPB) and to introduce a 5F pigtail catheter into the right internal jugular vein. For TLE via the subclavian route we used excimer laser sheath amended by mechanical sheath or snare if required.

Results: Patients were 66 ± 15 years of age and 74.4% were men. Mean lead dwell time was 93 ± 71 months. 239 pacing and 173 ICD leads were treated. The rate of dual coil ICD leads was 69.9%. TLE was complete for 401 of 412 leads (97.3%); 11 lead portions remained in situ. The femoral access was used in 19 patients (4.6%); emergent temporary pacing for cardiac arrest (4), occlusion balloon for SVC occlusion (1), extracorporeal membrane oxygenation and Impella for hemodynamic decompensation (1), diagnostic venography for atrial laceration (1) and prophylactic occlusion balloon placement for high-risk TLE (12). Mean procedural time was 102 ± 56 minutes with a mean fluoroscopy time of 11.8 ± 11.6 seconds. The overall complication rate was 2.8% including 3 major and 3 minor complications. Complete procedural or clinical success was achieved in 195 (94.2%) cases.

Conclusion: Placement of arterial and venous femoral sheaths might be useful to handle possible complications during TLE of chronically implanted pacing and ICD leads. Our experience suggests that, availability of these prophylactic introduced femoral sheaths can strengthen a team's response to complications and allows for safe and successful TLE.