Simultaneous lead traction from above and below: A novel technique to reduce the risk of superior vena cava injury during transvenous lead extraction

BACKGROUND Superior vena cava (SVC) injury is a rare but dreaded complication during percutaneous transvenous lead extraction (TLE) that carries high morbidity and mortality. Despite technological advances and improved efficacy, complication rates remain unchanged. OBJECTIVE We sought to develop and test a novel technique that could reduce the risk of SVC injury during TLE. METHODS Fifteen patients referred for TLE of an implantable cardioverter-defibrillator lead were included. Patients underwent fluoroscopic and intracardiac echocardiographic (ICE) imaging of the lead-SVC interface with traction from above, below, and simultaneously. Clinical characteristics, fluoroscopic and ICE findings, and procedural outcomes were collected and analyzed. RESULTS Fourteen of 15 patients were men (93%) with a mean age of 58 years. The mean lead dwell time was 8.09 +/- 3.97 years (range 1.08-16.25 years), and 12 of 15 leads (80%) were dual-coil. Acceptable ICE imaging was not possible in 3 of 15 patients (20%). Simultaneous traction showed greater leftward fluoroscopic shift compared with traction from above (24.96 +/- 8.82 mm vs 13.68 +/- 6.86 mm; P < .01), created greater separation between the lead and the SVC wall upon ICE imaging (2.0 +/- 0.52 mm vs 1.24 +/- 0.38 mm; P < .01), and maintained a more parallel relationship of the lead with the SVC wall (24.41 degrees +/- 4.14 degrees vs 27.91 degrees +/- 4.92 degrees; P < .05). CONCLUSION In patients presenting for TLE, 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 cleavage plane. This improved sheath alignment is particularly critical when powered sheaths are to be used.