Combined superior and femoral TLE 109 1. Introduction Transvenous lead extraction (TLE) is a technically complex procedure for the removal of indwelling leads and may be associated with serious complications including venous or cardiac perforation requiring emergency surgery. Cardiac implantable electronic device (CIED)-related infections and lead failures are important reasons for TLE. Despite the complexity of the procedure, TLE can be performed successfully using several approaches and tools, including simple manual traction, locking stylets, telescopic sheaths, femoral snares, mechanical powered sheaths and laser sheaths (1–4). Previous studies have shown that adding femoral snaring (bail-out) to a superior approach increases the complete procedural success rate (5–8). Some centers prefer femoral snaring as the primary approach with a complete procedural success rate of 94% in experienced centers (9, 10). However, the femoral approach has been associated with a higher complication and failure rate in comparison to other techniques in the ELECTRa prospective registry (11). The higher failure rate with the femoral approach in this registry may be biased as the femoral approach is usually used after failure of a superior approach in difficult cases. Instead of using the femoral snare tool as a bail-out procedure or as a primary approach, we adopted an approach where we used a low threshold to use a femoral snare or a combined superior and femoral approach in order to maximize the complete procedural success rate and to minimize complications. The rational of this approach is to free the lead from encapsulating fibrous or calcified tissue in the axillary-subclavian-brachiocephalic veins with a powered sheath (if necessary); to avoid mechanical dissection with the powered sheath in the superior vena cava (SVC) area to prevent SVC laceration; and to use the benefits of indirect traction (traction applied from an inferior approach) with the femoral snare. The aim of the current study was to assess the efficacy and safety of our approach. 7
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