DISCUSSION
Previous studies have shown that incorporating the femoral approach in addition to the superior approach results in a higher rate of complete procedural success during TLE.3,5 Furthermore, the femoral approach is favored as the primary approach and is associated with the successful advancement of a powered sheath through the superior approach. The technique for grasping leads with inaccessible ends via the femoral approach currently involves the use of an NES.3 When the NES is not coaxially aligned with the lead, the NES is ineffective for capture. We recommend against the prolonged use of the NES during combined superior and femoral approach lead extraction because excessive attempts may increase the risk of atrial injury.4Our proposed Wire TRUST technique enables a combined superior and femoral approach for TLE, even when the lead tip is difficult to free owing to severe adhesion. Additionally, this technique offers a safer and quicker alternative to the NES (Figure 3).
In Wire TRUST technique, there are two procedures to pass the 0.014-inch guidewire through the ONE Snare. The first procedure involves passing the 0.014-inch guidewire that has crossed the V lead through the snare in the IVC. Aligning the snare system coaxially with the 0.014-inch guidewire in the IVC is easier than aligning it in the RA, making passing the wire through the snare easier. Manipulating the 0.014-inch guidewire while keeping the pigtail catheter hooked to the V lead makes passing the wire through the snare easier because of improvement of operability of the 0.014-inch guidewire. Inserting a 0.035-inch guidewire into the pigtail catheter causes the pigtail portion to stretch and may release the hook on the V lead. Therefore, a 0.014-inch guidewire is essential for this technique.
The second procedure involves passing both ends of the wire through the snare outside the body after externalizing the 0.014-inch guidewire. The advantages of the Wire TRUST technique are low difficulty and safety. This technique is less difficult than using the NES because the pigtail catheter is softer and has better operability. A previous report showed the usefulness of a pigtail catheter for retrieving catheter fragments with inaccessible free ends.6 The safety of the Wire TRUST technique depends on which type of 0.014-inch guidewire is used. The 0.014-inch guidewire used for the Wire TRUST technique lacks sharp angles, similar to a NES, thereby suggesting a reduced risk of myocardial injury (Figure 2). Regarding the type of 0.014-inch guidewire, we consider the Nitinol guidewire (not stainless) to be safe because it has shape memory and does not have many sharp edges in the area where it grips the lead (Figure 2K).
Simultaneously inserting a 4Fr pigtail catheter and a 6Fr snare catheter is necessary. Therefore, a large-diameter sheath of ≥10Fr would theoretically be required for this technique (a 14Fr sheath was used in this case). Moreover, because of externalization of the 0.014-inch guidewire, manipulating the guidewire by pushing and pulling to adjust the position where the lead is held by the snare is easy (see Supplemental Video).
If the lead becomes free at the distal end during the procedure, continuing with the superior approach while holding the lead with the Wire TRUST technique or attempting to grasp the lead again from the distal end using the ONE Snare is possible. Therefore, the lead extractor should become familiar with this technique described here for safe TLE.
Conclusions
To the best of our knowledge, this is the first report of our novel Wire TRUST technique to grasp a lead with inaccessible ends and facilitate powered sheath advancement via the superior approach.