Chapter 7 112 If careful continuous steady direct traction fails to extract the lead from the lead vein entry site after freeing the lead from superior binding sites, a Needle’s Eye snare (Cook Medical) was used to extract the lead (Fig. 1c). Thus, we usually do not advance the Evolution sheath up to the tip of the lead. The Needle’s Eye snare has a double loop design which can be used to grasp free-floating lead extremities or the lead body. The 16F Introducer Sheath may not be large enough to accommodate a doubled-up ICD lead, depending on the location of snaring. When necessary, the proximal end of the lead was pulled down to the IVC and the free-floating end was grasped to avoid this issue. Sometimes a simultaneous hybrid superior and femoral approach was used to facilitate extraction and maintenance of vascular access where femoral snaring of the lead stabilizes the lead in order to perform mechanical powered dissection to free the lead and gain vascular access (12). The timing of device re-implantation, if needed, depended on the indication for TLE, need for ongoing CIED therapy and the complexity of the TLE procedure. Usually, if TLE was performed for lead malfunction, CIED re-implantation was performed during the same procedure. In patients with TLE for CIED-related infection, device reimplantation on the contralateral side was postponed until blood cultures were negative for at least 72 h. In PM-dependent patients with CIED infection, a temporary right ventricular bipolar active fixation lead was implanted through the right jugular vein. The lead was sutured to the patient’s skin with non-resorbable sutures and the lead was connected to a PM generator. 2.4 Definitions Definitions for procedural approach, techniques, outcomes and complications follow current expert consensus statements (1–3). Most definitions were initially based on the 2009 HRS expert consensus document on TLE (3); later expert consensus documents refined the definition of the size of portion of the lead that could be retained to be considered a clinical success (1, 2). Complete procedural success was defined as removal of all targeted leads and all lead material from the vascular space, with the absence of any permanently disabling complication or procedurerelated death. Clinical success was defined as removal of all targeted leads and lead material from the vascular space or retention of a small portion of the lead (<4 cm) that does not negatively impact the outcome goals of the procedure. A TLE
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