Case Report
A 49-year-old male patient had undergone a dual-chamber pacemaker (Accent MRI; Abbott, Chicago, IL, USA) implantation for intermittent complete atrioventricular block 9 years previously. He provided written informed consent to personal data treatment. He was referred to our hospital for TLE and replacement of the right ventricular (RV) lead (Tendril MRI LPA1200M/52cm; Abbott) after multiple presyncope episodes owing to electrical artifact on the RV lead (Figure 1A). There were no remarkable findings on a chest X-ray (Figure 1B). A pacemaker check at our hospital showed multiple episodes of electrical artifacts in the RV lead, but no issues with the right atrial (RA) lead (Tendril MRI LPA1200M/46cm; Abbott). The patient was scheduled for TLE, replacement of the RV lead, and pacemaker generator exchange.
We performed TLE with cardiac surgery backup in a hybrid operating room under general anesthesia using a combined superior and femoral approach called “Tandem” to achieve co-axial alignment of the powered sheath with the RV lead. Initially, we freed the device from its left prepectoral pocket, and dissected the RV lead free in the superior approach. We then inserted a locking stylet (Liberator Beacon Tip; Cook Medical Inc.), which could reach the lead tip, but the fixation helix of the RV lead could not be unscrewed. A locking stylet was then deployed and secured on the lead using a one-tie accessory (Cook Medical Inc.). After confirming the patency of the subclavian vein, we performed subclavian vein puncture more distally before the lead extraction procedure to establish a new access route for the new RV lead.
Simultaneously, we initiated the femoral approach using the Wire TRUST technique. The process of the Wire TRUST technique was as follows. First, A 14Fr sheath (Check-Flo Performer; Cook Medical Inc.) was inserted into the right common femoral vein. A 4Fr pigtail catheter (Terumo, Tokyo, Japan) was inserted into the 14Fr sheath and advanced in the RA by hooking the ventricular lead under multidirectional fluoroscopic guidance (Figure 2A). A 0.014-inch guidewire (Hi-Troque Command 300 cm; Abbott Vascular) was then inserted and advanced through the pigtail catheter. After crossing the ventricular lead, the 0.014-inch guidewire was further advanced to the inferior vena cava (IVC). A 6Fr snare catheter with a 35-mm-diameter loop (ONE Snare; Merit Medical) was inserted into the 14Fr sheath side-by-side with the pigtail catheter and then advanced into the IVC and opened in advance (Figure 2B). The distal side of the 0.014-inch guidewire was passed through the ONE Snare and withdrawn into the 14Fr femoral sheath for wire externalization (Figure 2C). After the removal of the pigtail catheter and 6Fr snare catheter, we passed both ends of the 0.014-inch guidewire through the snare outside of the body. The snare was then closed and reinserted into the 14Fr sheath (Figure 2D). After the snare catheter emerged from the tip of the sheath, the snare in the expanded position was advanced up to the vicinity of the lead (Figure 2E). Simultaneously advancing and closing the snare while tensioning the 0.014-inch guidewire after externalization securely held the lead (Figure 2F).
The RV lead was then extracted using a 14Fr GlideLight laser sheath (Philips, Amsterdam, The Netherlands) after firmly grasping it with the Wire TRUST technique (Figure 2G, H). A new RV lead (Tendril STS/2088TC-58cm; Abbott) was inserted using a newly established subclavian vein puncture site (Figure 2I). This lead was not removed because there were no issues with the data for the RA lead compared with before the procedure. The extracted lead showed fibrotic tissue with calcification (Figure 2J). A new generator (Assurity DR MRI; Abbott) was implanted, and the procedure was completed without any complications.