Maria Grazia Bongiorni, Giuseppe
Arena, Ezio Soldati, Maria Grana*, Claudio Comite*, Mario Mariani.
Cardiovascular and Pulmonary Department, University of Pisa,
*Anesthesiology Department, Pisa, Italy
|
|
The introduction of the new techniques for transvenous
lead removal in the clinical practice have changed the management of infected or abandoned
pacing leads1,2. These techniques proved to be very
effective and relatively safe3-7 when they are carried
out by experienced operators.
Among the factors affecting the outcome of the procedure and the risk of
complications, all the authors5,7-9 agree about the
difficulty to remove intravascular pacing leads.
There is an increasing interest around the improvement of both materials and
techniques to enhance the effectiveness of such procedures, and to reduce time and risks
of complications.
The incidence of lead adherence and their anatomical distribution were reported in a
wide survey5. Adherence to the venous and cardiac walls
are very frequent in the subclavian and innominate veins, as well as in the right atrium,
and particularly in the right ventricle at the tricuspid annulus and near the tip of the
lead.
Dilation of adherences by the dilator sheath is often highly symptomatic, inducing
severe parasympathetic stimulation in locally anesthetized patients. Dilation of very
tenacious adherences increase the risk of tears in the vascular wall requiring emergency
surgical repair8. Finally, failure to dilate the
adherences can be the cause of an unsuccessful procedure.
Another relevant problem is the removal of intravascular leads. More complex and
time-consuming procedures are required in case of intravascular leads; in addition, it is
very difficult to carry out dilation of adherences in such a condition, and
countertraction on the myocardial wall is also very difficult to perform2-8. Using the currently available transfemoral
workstation, the dilation of endoventricular adhaerences and countertraction require the
sheath to run through the inferior vena cava up into the right atrium, the tricuspid valve
and then into the right ventricle, following a very narrow bend. This is often impossible
to perform.
Our experience on transvenous leads removal confirm these observations9,10. We started to carry out transvenous removal in late
1989; since then, we have managed 382 leads, that had been implanted for a mean period of
62 months (range: 15 days 276 months). In 3.6% of the leads, it was impossible to apply
this technique. In the remaining 368 leads, the overall success rate was 91%. The 1.9% of
the leads were partially removed and the procedure was unsuccessful in 7.1% cases.
A lower success rate was observed in intravascular lead removal. Until 1994 we had
observed 14 intravascular pacing leads, among which 6 were atrial and 8 ventricular. The
removal success rate was 43%; in 5 of these leads, the technique was considered to be
inapplicable.
We investigated the causes of this unsatisfactory success rate in intravascular leads
comparied to the overall population. In our opinion, the unsuccessful outcome of the
procedure was due to the presence of extensive and tenacious adherences, and to the
impossibility to perform countertraction in the right ventricle using the transfemoral
workstation.
According to these observations we developed a new technique for percutaneous removal
of intravascular pacing leads.
The right internal jugular vein approach presents some advantages compared to the
traditional transfemoral approach: 1. it allows exposure of most intravascular leads (once
the lead is exposed, it is possible to use the stylets and the dilator sheaths to perform
an easier standard procedure); 2. the course of the lead from the internal jugular vein
and the right heart is more direct and straight, allowing easier dilation of the
adhaerences and countertraction, and reducing the risk of complications.
|
