Combined superior and femoral TLE 123 Fig. 1 Schematic overview of the combined lead vein entry site and femoral approach. a The axillarysubclavian-brachiocephalic veins usually contains the most abundant and resistant encapsulating tissue. b In the case of thrombosis of the superior veins or excessive fibrosis, dissection of encapsulating tissue using the Evolution RL or Evolution Shortie RL (CookMedical, Bloomington, IN, USA) was performed. The powered sheath was advanced over the lead body using counterpressure and countertraction. To reinforce the lead and reduce the risk of lead disruption, the lead was prepared with a Liberator locking stylet (Cook Medical, Bloomington, IN, USA) and One-Tie compression coil (Cook Medical, Bloomington, IN, USA). If needed, a guidewire can be placed through the sheath for maintaining venous access. Mechanical dissection in the SVC area was avoided if possible. c Removal of the lead by the femoral work station using a Needle’s Eye Snare (Cook Medical, Bloomington, IN, USA). The 16F outer femoral sheath can be used to perform counterpressure and countertraction. The proximal free end of the cut lead can be pulled down through binding sites in the superior vena cava area Fig. 2 Technique of lead removal for the total group and per indication group. There was a trend towards a relationship between groups with regard to the TLE technique used (P = 0.06). The use of the combined superior and femoral approach was numerically the highest in the patients undergoing TLE for lead malfunction 7
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