Chapters Transcript Video Laser-assisted lead removal Dr. Stuart Adler walks through a Laser-assisted lead removal, atrial lead extraction to gain venous access. D001227-02 My name is Dr Stewart Adler. Today's case study will involve a 70 year old gentleman referred for pacemaker X. Plant. Initially he underwent pacemaker implantation in 2001. Subsequently his battery reached end of life and he was referred for change out. His atrial lead, however had shown evidence of malfunction and it was recommended that this lead be removed. The patients pre procedure venogram show total occlusion of the subclavian vein at the affected site. It was recommended to the patient that he undergo lead extraction in order to obtain venus access. This would permit placement of a new atrial lead at the same site as his previously implanted ventricular lead and a successful generator. Change out standard sterile prep and drape is used in our laboratory for all patients undergoing extraction. It's important to consider the location of the incision in these patients. The angle of the leads as they exit the pocket and enter the subclavian vein will make a difference in the alignment of the extraction system, particularly the laser sheath as it's introduced into the body. Standard skin infiltration with lidocaine is performed to permit patient comfort and ready access into the patient's pocket. The skin incision is made and carried down through the subcutaneous tissue to expose the capsule pacemaker generator and leads the capsule around the devices and sized two carefully expanded from the pocket and once entered. The scar tissue can be gently broken, freeing the generator and leads. This will permit the X. Plantation of the generator and also allows the operator to visualize the scar tissue surrounding the leads and begin a plan to dissect that tissue and once freed, the operator can start to look into the exposed capsule and determine the extent of scar tissue in and around the leads. The leads are completely free from the encapsulating scar tissue. One can start to work on the X. Plant process For any given lead, the atrial lead is removed from the header and the ventricular lee is left attached to the pacemaker as this particular patient is pacemaker dependent. Now that the atrial lead is freed, it's important to identify the sutra sleeve in order for the laser apparatus to slide freely down the lead, the citrus leave and retention future must be removed. This will require some dissection at the top of the pocket before the lead enters the subclavian muscle and then down to the subclavian vein. The future sleeve is clearly identifiable and the retention future is now going to be cut with an 11 blade to free well lead and citrus lee from the underlying scar tissue. At this point the second retention future is cut and the future sleeve is freed. The future material will be removed completely prior to sliding the retention sleeve back to the base of the lead. At this point the style it is advanced fully into the distal aspect of the atrial lead. The lead will then be counterclockwise rotated such that the distal fixed helix screw will disengage from the atrium. At this point a subclavian venogram was performed. As you can see from this venogram, the lead entry site is completely occluded with marked dilatation of the collaterals around the shoulder and most of the contrast is emptying into the left internal jugular vein. The lead tip is completely free from the atrium. As previously mentioned, the patient has a completely occluded subclavian vein and we need to gain access to the patient's venus system at this point the lead can be cut and then sized for a locking style at the insulation is incised and then carefully pull free of the inner filers. In this particular lead, it's a side by side, double insulated filer construction so there will be no need to cut the second layer of insulation and it's now ready for the locking style. It. The coil expander is used to flare the distal aspect of the filers and ensure smooth passage of the locking style. It the lead is now ready for sizing. A sizing tool is used to ensure that the proper locking style that is used. Multiple locking style, it's are available and in order to achieve the appropriate fit and locking mechanism, the proper size needs to be used a non locking style. It is passed to the distal portion of the lead. This can be helpful in determining the exact length of locking style. It that will be inserted and ensure that the distal tip is advanced to the farthest aspect of the lead. I have chosen the spectrum X. L. L. D. E. Locking style. It for this particular lead removal, the L. L. D. E locking style, It offers two important advantages over other locking style. It's first the expanding coil permits locking the lead throughout its entire length and second. The flexible tip of this locking style at permits the style it to negotiate tight curves and tortuous angles that may present in certain challenging lead. Extraction the locking style, it is inserted into the lead and advanced to the distal aspect of the lead. This can be checked flores comically at that point, the lead is then locked by advancing the outer locking mechanism and fully engaging the mesh along the entire lead length. A future is then wrapped around the distal aspect of the lead along the outer insulation and tightly secured so that the lead insulation and fighters will be under constant traction Along with the locking style at the future is brought back to the lead locking future ring. It's important to keep the future material snug but not overly tight. It's then passed through the lead locking ring and it's nodded down at that point to secure the future. Along with the locking style out. A 12 French laser sheath has been chosen due to the patient's lead size. The laser sheath is calibrated by directing it at the detection screen at the front of the laser machine. Once calibrated the appropriate power, then can be supplied to the laser sheath for the extraction of the lead. The fish tape is advanced through the laser sheath and then locked on the distal loop. The locking style. It is pulled through the laser, including the future material until the locking style, it and sutra material are visible at the distal aspect of the laser sheath. The entire apparatus in is then advanced over the lead locking style. It and future utilizing the laser sheath is a two person operation. Once the sheath has been advanced to the level of the pocket, it's important to have control of the locking style at mechanism. In this particular case, I prefer to apply the traction to the locking style at and lead to know how much attention is being generated. I asked my assistant to help direct the sheath and the proper angle so that the lead and sheaths are well aligned. Prior to performing any cutting this flores, coptic view shows appropriate alignment of both laser sheet and lead as it courses into the vein between the first ribbon clavicle, the laser sheath has two components and outer and an inner. The outer sheath is retracted and the inner laser sheath is now being advanced into the subclavian vein. The same processes utilized to advance the laser sheath down the lead, little fiber optic tissues encountered at this point, and the sheath advances readily. The outer sheath is advanced, and the inner laser sheet now encounters some further fiber optic material. Powers applied to advance the laser sheath further over the atrial lead. You can see some buckling of the ventricular lead at this adhesion point. Once this final adhesion is removed, the atrial lead is quickly withdrawn into the laser sheet as the distal aspect of that lead is free. At this point, the lead is now completely within the outer and inner laser sheath, and the entire league can be withdrawn. Prior to removing the outer sheath, a guide wire is inserted into the vessel to ensure access into the venus system so that the New ager lead can be inserted. The expanded lead can now be seen and close up. There's a small amount of fiber optic tissue right at the proximal ring, but this was probably not significant. A little further back up the lead body. We'll be able to see some fiber optic bands that probably were the ones that were encountered just prior to the lead, popping free of the venus system and entering the laser sheath. At this point, venus access has been achieved. A new sheath can be delivered and the HR lead can be implanted without any difficulty. Published June 2, 2021 Created by
