Combined superior and femoral TLE 115 3.3 Complications An overview of in-hospital complications is presented in Table 4. The major and minor procedure-related complication rates were 1.1% and 10.2%, respectively. There was one case (0.4%) of emergent sternotomy for cardiac avulsion due to TLE. This was a 57-year-old woman with a dual-chamber ICD who had externalization of her Riata 1580 dual-coil shock lead which was in situ for 8 years. An Evolution RL sheath was used to free the lead up to the tricuspid annulus. After this maneuver, the patient became hemodynamic unstable and pericardial effusion was drained percutaneously. After complete removal of the ICD lead using the femoral snare, the patient deteriorated despite the drain and an emergent sternotomy was performed demonstrating laceration of the right atrial wall. She recovered clinically and at her last follow-up 5 years later, she is doing well. An overview of the complication rate per indication group is presented in Fig. 3. There were no procedure-related deaths; however, there were 5 in-hospital nonprocedure-related deaths after TLE (Table 5). Four patients with Staphylococcus aureus CIED related endocarditis died due to septic shock with multi-organ failure after an uncomplicated complete CIED removal. The interval between diagnosis of CIED-related endocarditis and the TLE procedure was 0, 1, 3 and 9 days. The last patient was presented late to our hospital. Patients who required TLE for a systemic infection had a higher risk of in-hospital nonprocedural-related death in comparison to patients with another indication (12.9% versus 0.4%, P = 0.001). 4. Discussion In this study, we evaluated the efficacy and safety of a liberal combined superior and femoral approach for TLE procedures. This approach was associated with a high complete and clinical success rate and a low major complication rate. There were no procedure-related deaths. 4.1 Individualized approach to TLE TLE has become an integral part of PM and ICD lead management. The number of TLE procedures has increased over the years as a consequence of an increase in CIED implantations, increasing rate of infections, lead failure, and development of extraction tools (2, 13). An individualized approach is paramount with respect to 7
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