Lead Extraction Overview

Transcription

1 Lead Extraction Overview Haitham Badran, MD, FESC Lecturer of Cardiology Ain Shams University

2 DO WE NEED IT

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7 Indications for Extraction Infection (sepsis) Damaged leads (arrhythmias, venous trauma) Unable to implant additional leads Thromboembolic events resulting from a retained lead Lead that interferes with the operation of another implanted device

8 Infection Reported in 4-7% of implants Erosion occurs when the generator and / or leads exit through the skin Staph Epi is the most common microbe while Staph Aureus (MRSA) more virulent Can be located in: The pacemaker pocket Along the lead (in biofilm) Within a compromised lead

9 To eradicate an infection, it is universally recognized that you must first: REMOVE ALL HARDWARE

10 Damaged Leads Can be caused by : Trauma to the lead Lead reaction to the hostile human body and subsequent material degradation Faulty implant technique Result of a lead extraction of another lead

11 Lead Failure: Fractured lead

12 ACCUFIX J LEAD TELECTRONICS INC.

13 ACCUFIX J LEAD TELECTRONICS INC.

14 Damaged Leads What are the problems? 1. Arrhythmias (Due to broken leads striking the epicardial wall) 2. Muscle stimulation 3. Endothelial wall damage 4. Potential puncture of heart wall and large vessel (J-wire design)

15 Unable to implant additional leads Too much implanted hardware Large vein occlusion Re-implanting through the same tract as that of the removed lead is the key

16 WHAT IS THE BIG DEAL TO PULL IT LIKE A MAN!!!!

17 The Chronic Lead 1. Binding scar tissue How does this happen?

18 The Problem.Adhesions - can occur wherever lead contacts the vessel wall Lead in contact with vessel wall

19 Scar tissue locations 36% 72% 48% Superior Approach 80% 41% 16% 71% Femoral Approach (20%)

20 The Chronic Lead 2. Poor lead design 3. Fragile materials

21 The Chronic Lead 4. Implant technique and lead entry location 5. Patient anatomy and physiology Everyone s different

22 Lead Extraction Minimal invasive transvenous approach Superior approach Access by the subclavian vein Access by the jugular vein Femoral Approach Access by the femoral vein

23 Superior Approach PROCEDURE PREPERATION: - Surgical Team on stand-by - Pericardiocentisis Set - Typed and crossed blood - TEE - High quality fluoroscopy - Thoracotomy tray (where appropriate)

24 Lead Extraction - Categories Lead Control locking stylet lead extender Vessel entry Evolution Shortie mechanical dilator sheath set Bryd Dilator stainless steel sheath sets Extraction superior approach Dilator sheath sets Poly & TFE Perfecta EDS Evolution mechanical dilator sheath set Needle s Eye Snare Extraction femoral approach Needle s Eye Snare Accessories

25 Lead Extraction - Categories Lead Control locking stylet lead extender Vessel entry Evolution Shortie mechanical dilator sheath set Bryd Dilator stainless steel sheath sets Extraction superior approach Dilator sheath sets Poly & TFE Perfecta EDS Evolution mechanical dilator sheath set Needle s Eye Snare Extraction femoral approach Needle s Eye Snare Accessories

26 Locking stylet Universal size: Single model is compatible with all known leads possessing an inner-lumen. [ inch]

27 LIBERATOR Locking Stylet In Action

28 LIBERATOR Locking Stylet In Action

29 LIBERATOR Locking Stylet In Action

30 LIBERATOR Locking Stylet In Action 30 2/20/2014

31 Lead Extraction - Categories Lead Control locking stylet lead extender Vessel entry Evolution Shortie mechanical dilator sheath set Bryd Dilator stainless steel sheath sets Extraction superior approach Dilator sheath sets Poly & TFE Perfecta EDS Evolution mechanical dilator sheath set Needle s Eye Snare Extraction femoral approach Needle s Eye Snare Accessories

32 BULLDOG lead extender Secures lumenless leads.

33 BULLDOG lead extender Used to extract lumen-less pacemaker and defibrillator leads. Other uses for Bulldog To extend a broken lead To extend a broken Liberator

34 Lead Extraction - Categories Lead Control Liberator locking stylet Bulldog lead extender Vessel entry Bryd Dilator stainless steel sheath sets Evolution Shortie mechanical dilator sheath set Extraction superior approach Dilator sheath sets Poly & TFE Perfecta EDS Evolution mechanical dilator sheath set Needle s Eye Snare Extraction femoral approach Needle s Eye Snare Accessories

35 Manual Mechanical Telescoping Stainless steel Dilator Sheath Sets STAINLESS STEEL

36 Lead Extraction - Categories Lead Control Liberator locking stylet Bulldog lead extender Vessel entry Bryd Dilator stainless steel sheath sets Evolution Shortie mechanical dilator sheath set Extraction superior approach Dilator sheath sets Poly & TFE Perfecta EDS Evolution mechanical dilator sheath set Needle s Eye Snare Extraction femoral approach Needle s Eye Snare Accessories

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40 Lead Extraction - Categories Lead Control Liberator locking stylet Bulldog lead extender Vessel entry Bryd Dilator stainless steel sheath sets Evolution Shortie mechanical dilator sheath set Extraction superior approach Dilator sheath sets Poly & TFE Perfecta EDS Evolution mechanical dilator sheath set Needle s Eye Snare Extraction femoral approach Needle s Eye Snare Accessories

41 LEAD EXTRACTION Manual Mechanical Telescoping Dilator Sheath Sets PTFE POLYPROPYLENE

42 Counter-Traction Bruce Wilkoff MD, Cleveland Clinic Foundation

43 What is Countertraction? 1 2 3

44 Lead Extraction - Categories Lead Control Liberator locking stylet Bulldog lead extender Vessel entry Bryd Dilator stainless steel sheath sets Evolution Shortie mechanical dilator sheath set Extraction superior approach Dilator sheath sets Poly & TFE Perfecta EDS Evolution mechanical dilator sheath set Needle s Eye Snare Extraction femoral approach Needle s Eye Snare Accessories

45 EDS - Electrosurgical Dissection Sheath Radiofrequency Ablation of fibrous adhesions PERFECTA Introduced into Europe ~ 2001

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47 Analysis Group Early cases * Accufix * Non-Accufix * Mechanical * Laser * Electrosurgical Ten Years of Lead Extraction Procedures Number It appears of Years that Removal the Outcome Cases Implanted Complete Partial Failed mechanical approach seems 1251 patients 2110 leads 985 patients 1237 leads 1011 patients 1743 leads 1456 patients 2279 leads 636 patients 1155 leads Major Complications 4.7 ± % 8% 6% 2.0% to be the safes approach 265 patients 459 leads 3.1 ± % 4% 2% 1.4% 4.5 ± % 6% 2% 1.5% Mechanical has a lower adverse 4.2 ± % 5% 2% 1.5% event rate than powered 5.8 ± % 4% 1% 2.7% sheaths 8.4 ± % 3..5% 0.6% 2.6% *Data presented at XIth World Symposium on Cardiac Pacing and Electrophysiology in Berlin, Dr Bruce Wilkoff

48 Lead Extraction - Categories Lead Control Liberator locking stylet Bulldog lead extender Vessel entry Bryd Dilator stainless steel sheath sets Evolution Shortie mechanical dilator sheath set Extraction superior approach Dilator sheath sets Poly & TFE Perfecta EDS Evolution mechanical dilator sheath set Needle s Eye Snare Extraction femoral approach Needle s Eye Snare Accessories

49 EVOLUTION Mechanical Dilator Sheath Sheath rotates when the trigger handle is squeezed for maximum operator control The patented threaded barrel tip provides succinct passage past fibrous binding sites without the forward depth of cut of other powered sheaths Available in four sizes that are compatible with both pacing and defibrillator leads: 7, 9, 11 & 13 Fr. (I.D.)

50 Lead Extraction - Categories Lead Control Liberator locking stylet Bulldog lead extender Vessel entry Bryd Dilator stainless steel sheath sets Evolution Shortie mechanical dilator sheath set Extraction superior approach Dilator sheath sets Poly & TFE Perfecta EDS Evolution mechanical dilator sheath set Needle s Eye Snare Extraction femoral approach Needle s Eye Snare Accessories

51 Alternative Approaches Pulling.. Weighed Traction Thoracotomy Or..

52 Femoral Approach NEEDLE S EYE snare Byrd Workstation Intravascular Retrieval Set

53 Femoral Techniques Capture of lead is normally attempted in the body of the right atrium RA RV

54 Needles-Eye Snare Fix

55 HRS Lead Extraction Consensus

56 Clinical Goals Elimination of infection pocket infection, device related endocarditis Venous access in an occluded vessel Elimination of an identified risk: lead or portion of a lead Perforation, arrhythmia Preservation of desired pacing mode Removal of all non-functional leads Resolution of pocket related symptoms pain HRS Lead Extraction Consensus

57 Major Complications Death Cardiac avulsion or tear Vascular avulsion or tear Pulmonary embolism Respiratory arrest or anesthesia related complication Stroke HRS Lead Extraction Consensus

58 Minor Complications Pericardial effusion Hemothorax Hematoma Arm swelling or thrombosis Vascular repair Pacing system related infection Air embolism Lead fragment migration Blood transfusion Pulmonary embolism HRS Lead Extraction Consensus

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