Combined superior and femoral TLE 119 5. Conclusions An effective and safe TLE procedure can be achieved by using a stepwise approach with a low threshold to use a combined superior and femoral approach. Thus, instead of using the femoral snare as a last resort, the use of the synergy between a superior and femoral approach may optimize the results of TLE. Compliance with ethical standards Conflicts of interest The authors declare that they have no conflicts of interest. Ethics approval The Medical Ethics Committee of the Erasmus MC reviewed the study (MEC-2018-1152), and this study was not subjected to the Dutch Medical Research Involving Human Subjects Act. The study was carried out according to the ethical principles for medical research involving human subjects established by Declaration of Helsinki, protecting the privacy of all the participants and the confidentiality of their personal information. References 1. Kusumoto FM, Schoenfeld MH, Wilkoff BL, Berul CI, Birgersdotter-Green UM, Carrillo R, et al. 2017 HRS expert consensus statement on cardiovascular implantable electronic device lead management and extraction. Heart Rhythm. 2017;14(12):e503–e51. 2. Bongiorni MG, Burri H, Deharo JC, Starck C, Kennergren C, Saghy L, et al. 2018 EHRA expert consensus statement on lead extraction: recommendations on definitions, endpoints, research trial design, and data collection requirements for clinical scientific studies and registries: endorsed by APHRS/HRS/LAHRS. Europace. 2018;20(7):1217. 3. Wilkoff BL, Love CJ, Byrd CL, Bongiorni MG, Carrillo RG, Crossley GH 3rd, et al. Transvenous lead extraction: Heart Rhythm Society expert consensus on facilities, training, indications, and patient management: this document was endorsed by the American Heart Association (AHA). Heart Rhythm. 2009;6(7):1085–104. 4. Bongiorni MG, Soldati E, Zucchelli G, di Cori A, Segreti L, de Lucia R, et al. Transvenous removal of pacing and implantable cardiac defibrillating leads using single sheath mechanical dilatation and multiple venous approaches: high success rate and safety in more than 2000 leads. Eur Heart J. 2008;29(23):2886–93. 5. Starck CT, Caliskan E, Klein H, Steffel J, Falk V. Impact of a femoral snare approach as a bailout procedure on success rates in lead extractions. Interact Cardiovasc Thorac Surg. 2014;18(5):551–5. 6. de Bie MK, Fouad DA, Borleffs CJ, et al. Trans-venous lead removal without the use of extraction sheaths, results of >250 removal procedures. Europace. 2012;14(1):112–6. 7. Buiten MS, van der Heijden AC, Schalij MJ, van Erven L. How adequate are the currentmethods of lead extraction? A review of the efficiency and safety of transvenous lead extraction methods. Europace. 2015;17(5):689–700. 8. Mazzone P, Migliore F, Bertaglia E, Facchin D, Daleffe E, Calzolari V, et al. Safety and efficacy of the new bidirectional rotational evolution(R) mechanical lead extraction sheath: results from a multicentre Italian registry. Europace. 2018;20(5):829–34. 9. Bracke FA, Dekker L, van Gelder BM. The Needle's eye snare as a primary tool for pacing lead extraction. Europace. 2013;15(7):1007–12. 7
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