Lead Extraction by Bi-Directional Approach using Excimer Laser Sheath and Snare

Abstract

An 80-year-old man had been diagnosed with sick sinus syndrome, for which he underwent dual chamber pacemaker implantation via the left subclavian vein 17 years previously. Atrial fibrillation was sustained and changed to the VVI mode at the time of generator replacement 6 years previously. The area that capped the atrial lead connector was stimulated, and skin fistula and pus were observed. The lead removal technique was then performed. Using a 12Fr Excimer laser sheath, the ventricular and atrial leads were peeled off alternately. There was resistance in the subclavian vein area and a mechanical sheath was used. The laser sheath was 14Fr, but it was difficult to remove at the superior vena cava site. Although transvenous lead extraction has a high success rate, it is more likely to have complications because of the long duration of implantation. Both of the leads in our case were fragile because of a long implantation time and difficult to remove using only an Excimer laser sheath. By grasping the lead with a snare from the femoral approach, pulling the snare and the locking device of the collarbone at the same time from both sides simultaneously allowed passage of the laser sheath and both leads could be removed. We experienced a case in which the bi-directional approach of an Excimer laser sheath and snare was effective for transvenous extraction of old leads.