Combined superior and femoral TLE 111 veins and need for temporary pacing. In pacing-dependent patients, a temporary pacing wire was inserted from the femoral or jugular vein. 2.3 Lead extraction approach In general, we used a stepwise approach for TLE. A horizontal incision was made to permit easy access to the venous entry site. Tissue debridement was performed, especially in patients with pocket infection, and leads were dissected free to their venous entry site with removal of the anchor sleeves. If reimplantation was planned, then ipsilateral venous access was gained and guidewire(s) passed into the SVC if the vein was not occluded. If present, the active-fixation mechanism was retracted, and manual traction was attempted with a standard stylet in place. If lead removal with manual traction was unsuccessful, the lead was cut and a Liberator Beacon tip locking stylet (Cook Medical, Bloomington, IN, USA) and One-Tie Compression Coil (Cook Medical) were placed. The Liberator locking stylet provides focal traction at the tip of the lead and stabilizes the lead. The One-Tie device binds the proximal lead components and locking stylet together. When lead removal with a locking stylet was still unsuccessful, we either proceeded with a mechanical powered sheath or a femoral snare. If resistance was encountered in the superior veins, a mechanical powered sheath was used to dissect the lead from encapsulating fibrous tissue at proximal binding sites (Fig. 1). If no superior binding sites were encountered and venous access could be established in the case of a reimplantation, then a femoral snare was directly used (without the need for a powered sheath). The rotational mechanism of the hand-powered sheath (11F/13F Evolution and 9F/11F Evolution Shortie, from 2013: Evolution RL and Evolution Shortie RL, Cook Medical) permits movement along the lead body by cutting fibrous or even calcified tissue using the stainless-steel spiral cut dissection tip. The outer telescoping polymer sheath protects the venous wall from the metal cutting tip while advancing over the lead in tracts free from adhesions. In case of occluded superior veins and the need for reimplantation, we placed a guidewire through the outer sheath after creating a path through the adhesions in the superior veins (Fig. 1b). We avoided mechanical dissection in the area of the SVC to prevent SVC laceration, unless there was a dual-coil shock lead with dense fibrotic adhesions. 7
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