New Insights in Central Venous Disorders. The Role of Transvenous Lead Extractions

Abstract

Over the last decades, the implementation of new technology in cardiac pacemakers and defibrillators as well as the increasing life expectancy have been associated with a higher incidence of transvenous lead complications over time. Variable degrees of venous stenosis at the level of the subclavian vein, the innominate trunk and the superior vena cava are reported in up to 50% of implanted patients. Importantly, the number of implanted leads seems to be the main risk factor for such complications. Extraction of abandoned or dysfunctional leads is a potential solution to overcome venous stenosis in case of device upgrades requiring additional leads, but also, in addition to venous angioplasty and stenting, to reduce symptoms related to the venous stenosis itself, i.e., the superior vena cava syndrome. This review explores the role of transvenous lead extraction procedures as therapeutical option in case of central venous disorders related to transvenous cardiac leads. We also describe the different extraction techniques available and other clinical indications for lead extractions such as lead infections. Finally, we discuss the alternative therapeutic options for cardiac stimulation or defibrillation in case of chronic venous occlusions that preclude the implant of conventional transvenous cardiac devices.

Keywords: leadless cardiac pacemaker; subcutaneous cardioverter defibrillator; superior vena cava syndrome; transvenous lead extractions; venous stenosis.

Figure 1

Current therapeutic approach to treat or overcome venous stenosis/occlusion related to transvenous cardiac leads.

Figure 2

Tools and techniques currently in use to perform percutaneous TLEs [Figure text adapted from Bongiorni et al. (1) and from (41)].

Figure 3

Examples of transvenous leads extracted using mechanical sheaths. (a) Ventricular pacing lead (passive fixation) extracted using a manual non-powered sheath (Philips SightRail™ 11.5F). Tissue adhesions (arrow) at the tricuspid valve level were dissected advancing the sheath while applying a pushing rotational force that explains kicking of the shaft. (b) Active fixation pacing leads extracted while advancing a rotational mechanical sheath (Philips TightRail™ 9F) mounted on the atrial lead. Once the retroclavicular adhesions were overcome, the atrial lead was easily extracted and dragged out together with the ventricular lead because of fibrous tissue (arrow) bounding the leads together at the brachiocephalic vein level.

Figure 4

Examples of non-transvenous CIEDs systems to deliver cardiac pacing or defibrillation therapy. (a) A leadless PM (Micra™ Medtronic, top-left corner) and the site of implant at the apical-septal level of the right ventricle (arrow). The insert at the top right corner shows a step of a Micra™ implantation: the catheter delivery system (dashed arrow) is advanced into the right ventricle to deliver the device. (b) A subcutaneous ICD (Emblem™ MRI Model A219, Boston Scientific, top-right corner) and the site of implant of the device (solid arrow) and the lead (dashed arrow). The device is implanted in the left axillary region in an intermuscular pocket created between the serratus anterior and the latissimus dorsi muscles, and connected to the lead implanted in the subcutaneous tissue of the parasternal region of the chest.