Combined superior and femoral TLE 117 4.3 Liberal combined superior and femoral approach Instead of using femoral snaring as a primary approach or as a bail-out tool, we adopted a novel approach where we used a liberal combined superior and femoral approach or femoral approach only. Major advantages of this approach are (1) maintaining superior venous access in contrast to a strictly femoral approach in case of occluded veins; (2) reducing the resistance on the proximal lead when pulling the lead down from the femoral workstation after freeing the lead from the superior binding sites; (3) avoiding hemodynamic instability by failure of the lead to return to its original position (slippage of lead body through binding site) after direct traction from the vein entry site; and (4) avoiding risk of SVC laceration in contrast to a strictly superior approach (17, 18). These advantages are especially relevant in case of occluded superior veins. Complete venous occlusion occurs relatively frequently (approximately 10%) after CIED implantation (19), and especially in patients undergoing TLE for device infection (up to 32%) (20). The complete procedural success rate and clinical success rate in our study was 90.2% and 97.7%, respectively, and complete extraction was achieved for 94.1% of leads (complete lead removal rate). There was one case (0.4%) of cardiac avulsion requiring emergent surgery, highlighting the relative safety of this approach. This cardiac avulsion occurred in a patient where we had to dissect the dual-coil ICD lead from the SVC using the powered sheath. Despite the use of traction from above to provide a tight “rail”, there was probably an unfavourable sheath-SVC wall geometric relationship creating a RA laceration. Freeing dual-coil ICD leads from severe SVC binding sites may be challenging. For these cases, Schaller et al. have described an interesting technique to reduce the risk of SVC injury by using simultaneous lead traction from above and below (with a femoral snare) during advancement of a powered sheath (21). Simultaneous traction results in increased separation and a more parallel alignment of the lead and SVC wall, allowing the sheath to be better oriented in the desired lead-vein cleavage plane. The results of our liberal combined superior and femoral approach are in agreement with the outcomes of high-volume centers (≥ 30 TLE procedures/year) in the ELECTRa registry (TLE procedures between 2012 and 2014) with regard to clinical 7
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