Efficacy and safety of transvenous lead extraction using a liberal combined superior and femoral approach

Abstract Purpose During transvenous lead extraction (TLE), the femoral snare has mainly been used as a bail-out procedure. The purpose of the present study is to evaluate the efficacy and safety of a TLE approach with a low threshold to use a combined superior and femoral approach. Methods This is a single-center observational study including all TLE procedures between 2012 till 2019. Results A total of 264 procedures (median age 63 (51–71) years, 67.0% male) were performed in the study period. The main indications for TLE were lead malfunction (67.0%), isolated pocket infection (17.0%) and systemic infection (11.7%). The median dwelling time of the oldest targeted lead was 6.8 (4.0–9.7) years. The techniques used to perform the procedure were the use of a femoral snare only (30%), combined rotational powered sheath and femoral snare (25%), manual traction only (20%), rotational powered sheath only (17%) and locking stylet only (8%). The complete and clinical procedural success rate was 90.2% and 97.7%, respectively, and complete lead removal rate was 94.1% of all targeted leads. The major and minor procedure-related complication rates were 1.1% and 10.2%, respectively. There was one case (0.4%) of emergent sternotomy for management of cardiac avulsion. Furthermore, there were 5 in-hospital non-procedure-related deaths (1.9%), of whom 4 were related to septic shock due to a Staphylococcus aureus endocarditis after an uncomplicated TLE with complete removal of all leads. Conclusion An effective and safe TLE procedure can be achieved by using the synergy between a superior and femoral approach.

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Comparison of outcomes in infected cardiovascular implantable electronic devices between complete, partial, and failed lead removal: an ESC-EHRA-EORP ELECTRa (European Lead Extraction ConTrolled) registry

EP Europace ◽

10.1093/europace/euz269 ◽

2019 ◽

Vol 21 (12) ◽

pp. 1876-1889 ◽

Cited By ~ 1

Author(s):

Eyal Nof ◽

Maria Grazia Bongiorni ◽

Angelo Auricchio ◽

Christian Butter ◽

Nikolaos Dagres ◽

...

Keyword(s):

Strong Predictor ◽

Electronic Devices ◽

Complete Removal ◽

Lead Extraction ◽

Lead Removal ◽

Complication Rates ◽

Failure Group ◽

Cardiac Implantable Electronic Devices ◽

Procedural Complications ◽

Locking Stylet

Abstract Aims The present study sought to determine predictors for success and outcomes of patients who underwent cardiac implantable electronic devices (CIED) extraction indicated for systemic or local CIED related infection in particular where complete lead removal could not be achieved. Methods and results ESC-EORP ELECTRa (European Lead Extraction ConTRolled Registry) is a European prospective lead extraction registry. Out of the total cohort, 1865/3510 (52.5%) patients underwent removal due to CIED related infection. Predictors and outcomes of failure were analysed. Complete removal was achieved in 1743 (93.5%) patients, partial (<4 cm of lead left) in 88 (4.7%), and failed (>4 cm of lead left) in 32 (1.8%) patients. Removal success was unrelated to type of CIED infection (pocket or systemic). Predictors for failure were older leads and older patients [odds ratio (OR) 1.14 (1.08–1.19), P < 0.0001 and OR 2.68 (1.22–5.91), P = 0.0146, respectively]. In analysis by lead, predictors for failure were: pacemaker vs. defibrillator removal and failure to engage the locking stylet all the way to the tip [OR 0.20 (0.04–0.95), P = 0.03 and OR 0.32 (0.13–0.74), P = 0.008, respectively]. Significantly higher complication rates were noted in the failure group (40.6% vs. 15.9 for partial and 8.7% for success groups, P < 0.0001). Failure to remove a lead was a strong predictor for in hospital mortality [hazard ratio of 2.05 (1.01–4.16), P = 0.046]. Conclusion A total of 6.5% of infected CIED patients failed attempted extraction. Only were >4 cm of lead remained resulted in higher procedural complications and mortality rates.

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Efficacy and mortality of rotating sheaths versus laser sheaths for transvenous lead extraction: a meta-analysis

Journal of Interventional Cardiac Electrophysiology ◽

10.1007/s10840-021-01076-x ◽

2021 ◽

Author(s):

Sun Yong Lee ◽

Isabel E. Allen ◽

Celso Diaz ◽

Xiaofan Guo ◽

Cara Pellegrini ◽

...

Keyword(s):

Removal Rate ◽

Meta Analysis ◽

Case Series ◽

Complete Removal ◽

Lead Extraction ◽

Lead Removal ◽

Success Rates ◽

Risk Of Death ◽

The Mean ◽

Mean Time

Abstract Background Rotating and laser sheaths are both routinely used in transvenous lead extraction (TLE) which can lead to catastrophic complications including death. The efficacy and risk of each approach are uncertain. To perform a meta-analysis to compare success and mortality rates associated with rotating and laser sheaths. Methods We searched electronic academic databases for case series of consecutive patients and randomized controlled trials published 1998–2017 describing the use of rotating and laser sheaths for TLE. Among 48 studies identified, rotating sheaths included 1,094 patients with 1,955 leads in 14 studies, and laser sheaths included 7,775 patients with 12,339 leads in 34 studies. Patients receiving rotating sheaths were older (63 versus 60 years old) and were more often male (74% versus 72%); CRT-P/Ds were more commonly extracted using rotating sheaths (12% versus 7%), whereas ICDs were less common (37% versus 42%), p > 0.05 for all. Infection as an indication for lead extraction was higher in the rotating sheath group (59.8% versus 52.9%, p = 0.002). The mean time from initial lead implantation was 7.2 years for rotating sheaths and 6.3 years for laser sheaths (p > 0.05). Results Success rates for complete removal of transvenous leads were 95.1% in rotating sheaths and 93.4% in laser sheaths (p < 0.05). There was one death among 1,094 patients (0.09%) in rotating sheaths and 66 deaths among 7,775 patients (0.85%) in laser sheaths, translating to a 9.3-fold higher risk of death with laser sheaths (95% CI 1.3 to 66.9, p = 0.01). Conclusions Laser sheaths were associated with lower complete lead removal rate and a 9.3-fold higher risk of death.

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Lead extractions: dissecting adhesions up to the lead-tip of the right ventricle: safety and success-rates

10.22541/au.161309488.83040385/v1 ◽

2021 ◽

Author(s):

Olivier Witte ◽

Peter Delnoy ◽

Abdul Ghani ◽

Jaap Jan Smit ◽

Anand Ramdat Misier ◽

...

Keyword(s):

Right Ventricle ◽

Major Complication ◽

Complete Removal ◽

Lead Extraction ◽

Complication Rates ◽

Evolution System ◽

Success Rates ◽

Significant Difference ◽

Group B ◽

The Right

Objectives and Background: Goal of Transvenous Lead Extraction (TLE) is complete removal of all targeted leads, without complications. Despite counter traction manoeuvres, efficacy rates are often hampered by broken right ventricle lead (RV-lead) tips. Mechanically powered lead extraction (Evolution sheath) is effective, however safety of dissection up to the lead tip is unclear. Therefore, we examined the feasibility and safety of RV-lead extraction requiring dissection up to the myocardium. Methods and results: From 2009 to 2018, all TLE in the Isala Heart Centre (Zwolle, The Netherlands) requiring the hand-powered mechanical Evolution system to extract RV-leads (n=185) were examined from a prospective registry. We assessed 2 groups: TLE with the first generation Evolution (n=43) with (A1,n=18) and without (A2,n=25) adhesions up to the myocardium and TLE with the Novel R/L type (n=142) of sheath with (B1,n=59) and without (B2,n=83) adhesions up to the myocardium. Complete success rate in Group B was significantly higher than group A (96.5 vs 76.7%, p=0.0354). When comparing the patients with adhesions up to the myocardium, total complete success is higher in the R/L group (61.1% vs 90.5%, p=0.0067). There were no deaths. Overall major complication rates were low (2/185;1.1%) and there was no statistically significant difference in major and minor complications between the two groups. Conclusion: Extraction strategy with the bidirectional Evolution R/L sheath for right ventricular leads with adhesions up to the myocardium is safe and feasible.

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P1179Transvenous extraction of partially controlled leads

EP Europace ◽

10.1093/europace/euaa162.370 ◽

2020 ◽

Vol 22 (Supplement_1) ◽

Author(s):

A Benak ◽

G Bencsik ◽

A Makai ◽

R Pap ◽

G Klausz ◽

...

Keyword(s):

Success Rate ◽

Essential Role ◽

Independent Predictor ◽

Lead Extraction ◽

Limited Data ◽

Partial Control ◽

Femoral Approach ◽

Lower Success Rate ◽

The Mean ◽

Locking Stylet

Abstract Background Lead control has an essential role in successful transvenous lead extraction (TLE), however, there is limited data about leads without adequate control Objective The aim of the study was to assess the success rate, complexity, and safety of partially controlled lead extraction. Methods A single-center retrospective analysis of consecutive patients underwent TLE procedures was performed. Results From May 2012 to Aug 2019, 137 consecutive patients (76% male, mean age: 65 ± 15 years) underwent TLE procedures (273 leads, 93% infective indication, 37% with high voltage leads). Locking stylet was used in 83% (n = 224) of the leads. Advancement of the locking stylet all the way to the tip was not possible in 30.4% (n = 68) of the leads, resulting in partial control (LC- group). The mean age of the lead was significantly higher (11.06 +/- vs 7.76 +/- 6.3, p = 0.001) and the success rate was lower (76.1 % vs 93.2%, p = 0.001) in LC-. The need for femoral approach was more frequently in LC- leads (36.9% vs 16.2%, P= 0.001). Inadequate lead control was an independent predictor of lead extraction failure (OR: 5.27, 95% CI: 1.71-5.27, p= 0.004) and femoral approach (OR: 2.1, 95% CI: 1.054-4.08, p= 0.035). Three out of five major complications occurred in LC- group. Conclusions Partial lead control results in lower success rate and more complex TLE procedures.

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P1507Experience in chronical lead extraction with ablation catheter and snare via femoral route

EP Europace ◽

10.1093/europace/euaa162.311 ◽

2020 ◽

Vol 22 (Supplement_1) ◽

Author(s):

A Uslu ◽

A Kup ◽

S Demir ◽

I Balaban ◽

K Gulsen ◽

...

Keyword(s):

The Body ◽

Snare Complex ◽

Lead Extraction ◽

Time Interval ◽

Ablation Catheter ◽

Femoral Approach ◽

Icd Leads ◽

Locking Stylet ◽

Gooseneck Snare ◽

Manual Traction

Abstract Background Transvenous lead extraction may become a complicated process and special sheath systems used for extraction may not be available in the laboratory. Transvenous lead extraction from femoral vein by using ablation catheter and snare may be an alternative and cost-effective method to transvenous lead extraction with specialized lead extraction sheaths. The aim of the present study is to evaluate the factors that may be associated with the use of transfemoral technique during extraction of chronically implanted leads. Methods We retrospectively analyzed consecutive patients who underwent transvenous extraction of pacemaker, cardiac resynchronization therapy (CRT) and intracardiac defibrillator (ICD) leads in our institution in between 01.01.2016 and 01.01.2019. The indications for lead extraction were based on the European Heart Rhythm Association recommendations. Manual traction was applied to all leads at the beginning of each case. If manual traction was not successful, a subclavian approach by using locking stylet (Liberator Universal Locking Stylet, Cook Medical) or femoral approach was used. Femoral approach was performed using the flexible 13F long sheath and a second sheath for ablation catheter. Ablation catheter was wrapped around the lead and the tip of the ablation catheter was caught with gooseneck snare. Downward traction was applied on the body of the lead by using ablation catheter and gooseneck snare complex to release either end of the lead. Results A total of 160 leads in 94 patients were extracted during the time interval between 01.01.2016 and 01.01.2019. The indications for extraction were cardiac device related pocket erosion and infection in 71 (75.6%) and lead failure in the 23 (24.4%) cases. Extracted system was ICD in 48 (51.1%), CRT in 9 (9.6%) and pacemaker in 37 (39.3%) cases. The median time from the preceding procedure was 62.5 (IQR:32.3- 95.3) months. Lead extraction was performed by manual traction in 35 (37.2%) patients, by locking stylet method in 7 (7.4%) and by femoral approach in 52 (55.3%) patients. Clinical success was achieved in 93 (98.9%) cases and all of the patients discharged uneventfully without a major complication as death, cardiac avulsion or tear requiring pericardiocentesis or emergent surgery. Procedural success with femoral approach was achieved in 51/52 (98%) patients (99 leads). Ordinal regression revealed the time from the preceding procedure as the only parameter that was significantly associated with the usage of femoral approach (OR:1.065 ( 95% CI 1.039-1.100) p < 0.001). Conclusion Based on our experience, transfemoral approach by using ablation catheter and gooseneck snare seems to be an effective and safe method for chronically implanted lead extraction. It may be particularly be useful when manual traction is unsuccessful and special toolkids are not available for extraction.

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Is jumbo biopsy forceps comparable to cold snare for diminutive colorectal polyps? – a meta-analysis

Endoscopy International Open ◽

10.1055/a-1293-6965 ◽

2021 ◽

Vol 09 (01) ◽

pp. E9-E13

Author(s):

Sachin Srinivasan ◽

Peter D. Siersema ◽

Madhav Desai

Keyword(s):

Meta Analysis ◽

Complete Removal ◽

Colorectal Polyps ◽

Comparable Efficacy ◽

Incomplete Resection ◽

Complication Rates ◽

Biopsy Forceps ◽

Significant Difference ◽

Leave One Out ◽

Endoscopic Assessment

Abstract Background and study aims Diminutive colorectal polyps are increasingly being detected and it is not clear whether jumbo biopsy forceps (JBF) has comparable efficacy to that of cold snare polypectomy (CSP) for management of these lesions. Methods An electronic literature search was performed for studies comparing resection rates of JBF and CSP for diminutive polyps (≤ 5 mm). The primary outcome was incomplete resection rate (IRR). Secondary outcomes included failure of tissue retrieval and complication rates (post-polypectomy bleeding, perforation etc.). Leave-one-out analysis was performed to examine the disproportionate role of any of the studies. Meta-analysis outcomes and heterogeneity (I2) were computed using Comprehensive meta-analysis software. Results A total of 4 studies (3 randomized controlled trials and 1 retrospective study) with 407 patients and 569 total polyps (mean size of 3.62 mm) was included for analysis. IRR of JBF was slightly higher than that of CSP (10.2 % vs 7.2 %) but this was not statistically significantly different (Pooled OR 1.76; 95 % CI 0.94–3.28; I2 = 0). Leave-one-out analysis showed no significant difference in the pooled OR comparison either. Two of the 4 studies reported 0 % failure of tissue retrieval for JBF and 1 % and 4.3 % for CSP. There were no complications for either group from the 2 studies that reported this outcome. The quality of the included studies was moderate to high. Conclusions This systematic review with only limited data shows that JBF and CSP are not statistically different in completely removing diminutive polyps, although careful endoscopic assessment is needed to ensure complete removal of all polyp tissue.

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Finnish flow diverter study: 8 years of experience in the treatment of acutely ruptured intracranial aneurysms

Journal of NeuroInterventional Surgery ◽

10.1136/neurintsurg-2021-017641 ◽

2021 ◽

pp. neurintsurg-2021-017641

Author(s):

Kemal Alpay ◽

Tero Hinkka ◽

Antti E Lindgren ◽

Juha-Matti Isokangas ◽

Rahul Raj ◽

...

Keyword(s):

Mortality Rate ◽

Intracranial Aneurysms ◽

Aneurysmal Subarachnoid Hemorrhage ◽

Flow Diverter ◽

Supporting Evidence ◽

Complication Rates ◽

Related Complication ◽

Anterior Circulation ◽

Clinical And Radiological Results ◽

Ruptured Intracranial Aneurysms

BackgroundFlow diversion of acutely ruptured intracranial aneurysms (IAs) is controversial due to high treatment-related complication rates and a lack of supporting evidence. We present clinical and radiological results of the largest series to date.MethodsThis is a nationwide retrospective study of acutely ruptured IAs treated with flow diverters (FDs). The primary outcome was the modified Rankin Scale (mRS) score at the last available follow-up time. Secondary outcomes were treatment-related complications and the aneurysm occlusion rate.Results110 patients (64 females; mean age 55.7 years; range 12–82 years) with acutely ruptured IAs were treated with FDs between 2012 and 2020 in five centers. 70 acutely ruptured IAs (64%) were located in anterior circulation, and 47 acutely ruptured IAs (43%) were blister-like. A favorable functional outcome (mRS 0–2) was seen in 73% of patients (74/102). Treatment-related complications were seen in 45% of patients (n=49). Rebleeding was observed in 3 patients (3%). The data from radiological follow-ups were available for 80% of patients (n=88), and complete occlusion was seen in 90% of aneurysms (79/88). The data from clinical follow-ups were available for 93% of patients (n=102). The overall mortality rate was 18% (18/102).ConclusionsFD treatment yields high occlusion for acutely ruptured IAs but is associated with a high risk of complications. Considering the high mortality rate of aneurysmal subarachnoid hemorrhage, the prevention of rebleeding is crucial. Thus, FD treatment may be justified as a last resort option.

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Efficacy and Safety of Cone-Beam Computed Tomography-Derived Augmented Fluoroscopy Combined with Endobronchial Ultrasound in Peripheral Pulmonary Lesions

Respiration ◽

10.1159/000515181 ◽

2021 ◽

pp. 1-9

Author(s):

Kai-Lun Yu ◽

Shun-Mao Yang ◽

Huan-Jang Ko ◽

Hui-Yu Tsai ◽

Jen-Chung Ko ◽

...

Keyword(s):

Computed Tomography ◽

Propensity Score ◽

Cone Beam Computed Tomography ◽

Diagnostic Yield ◽

Endobronchial Ultrasound ◽

Cone Beam ◽

Complication Rates ◽

Efficacy And Safety ◽

Pulmonary Lesions ◽

Peripheral Pulmonary Lesions

Background: The diagnostic yield of peripheral pulmonary lesions (PPLs) using radial endobronchial ultrasound (EBUS) remains challenging without navigation systems. Cone-beam computed tomography-derived augmented fluoroscopy (CBCT-AF) represents a recently developed technique, and its clinical utility remains to be investigated. Objectives: The aim of this study was to investigate the diagnostic yield of transbronchial biopsy (TBB) using a combination of CBCT-AF and radial EBUS. Methods: We recruited consecutive patients with PPLs who underwent radial EBUS-guided TBB, with or without AF, between October 2018 and July 2019. Following propensity score 1:1 matching, we recorded the procedure-related data and measured their efficacy and safety. Results: While 72 patients received EBUS-plus-AF, 235 patients received EBUS only. We included 53 paired patients following propensity score matching. The median size of lesions was 2.8 and 2.9 cm in the EBUS-plus-AF group and EBUS-only group, respectively. Diagnostic yield was higher in the former group (75.5 vs. 52.8%; p = 0.015). The diagnostic yield for the EBUS-plus-AF group was significantly higher for lesions ≤30 mm (73.5 vs. 36.1%; p = 0.002). Moreover, there was no significant difference in the complication rates (3.8 vs. 5.7%; p = 1.000). Twenty-four nodules (45.3%) were invisible by fluoroscopy in the EBUS-plus-AF group. All of them were identifiable on CBCT images and successfully annotated for AF. The mean radiation dose of total procedure, CBCT, and fluoroscopy was 19.59, 16.4, and 3.17 Gy cm2, respectively. Conclusions: TBB using a combination of CBCT-AF and EBUS resulted in a satisfactory diagnostic yield and safety.

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New Therapeutic Approach to Reduce Methotrexate Toxicity after High-Dose Chemotherapy in a Child with Acute Lymphocytic Leukemia: Efficacy and Safety of Hemoadsorption with HA-230 Adsorber

Blood Purification ◽

10.1159/000514135 ◽

2021 ◽

pp. 1-5

Author(s):

Vitaliy Sazonov ◽

Zaure Tobylbayeva ◽

Askhat Saparov ◽

Bolatbek Jubaniyazov ◽

Samat Issakov ◽

...

Keyword(s):

Acute Lymphocytic Leukemia ◽

Pediatric Patients ◽

High Dose Chemotherapy ◽

The Body ◽

Lymphocytic Leukemia ◽

High Dose ◽

Successful Implementation ◽

Efficacy And Safety ◽

Related Complication ◽

Dose Methotrexate

Background: High-dose methotrexate (HDMTX) is likely to cause a number of side effects and manifest itself as hepatotoxicity, nephrotoxicity, mucositis, and neurotoxicity. A several studies demonstrated the efficacy of extracorporeal detoxification methods such as plasma exchange, hemodialysis (HD), HD filtration, and hemoperfusion for the treatment of MTX delayed clearance. However, none of the existing methods as effective as expected and limited for general implementation due to a procedure-related complication. Case Report: Here, we report a successful implementation of HA-230 hemoadsorption procedure to remove cumulated MTX from the body and reduce its toxicity in a child with ALL after high-dose chemotherapy. Results and Conclusion: Based on our results, single-hemoadsorption procedure with the HA-230 adsorber in case of delayed methotrexate clearance was safe and well-tolerated in a pediatric patient with ALL and would significantly improve the patient’s condition. Further studies need to demonstrate its safety and efficacy in a large number of pediatric patients.

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