TLE procedures
Before the TLE procedures, all patients performed cardiac CT and angiography to assess any extravascular or extracardiac lead positioning, identify the sites of any venous occlusions or stenosis, and assess the regions of lead mobility and adherence. All the procedures were performed by experienced electrophysiologists under conscious sedation or general anesthesia in the cardiac surgery operating room with cardiovascular surgeon backup. A temporary pacing wire was inserted from the femoral vein before the procedure. The invasive arterial pressure and intracardiac or transesophageal echocardiography monitoring were recorded and cardiopulmonary bypass equipment was always on standby during the procedure.
All leads were extracted transvenously through a subclavian or femoral approach using the following 4 techniques; (1) manual traction using normal or locking stylets, (2) laser-assisted lead extraction using an excimer laser sheath (3) a mechanical sheath extraction using a non-powered polypropylene dilator sheath (Cook Medical, USA) or a bidirectional rotational mechanical sheath (Evolution RL, Cook Medical, USA), or (4) a snare-assisted lead extraction using various snare tools such as Goose neck snare (Medtronic, Minneapolis, MN, USA), Needle’s eye snare (Cook Medical, USA), and Lassos (Osypka, GmbH, Grentzig-Whylen, Germany). 18 Following manual traction, a mechanical sheath extraction and/or laser-assisted lead extraction was selected based on whether there was a venous occlusion or stenosis, lead-lead or lead-tissue adherence, or extensive calcification. Alternatively, among those with severe adhesions in the subclavian, innominate, or superior vena cava veins, a femoral approach using the snaring technique was applied once the tip of the passive fixation lead became free. After the removal of the entire system, an active-fixation pacing lead was immediately implanted from the jugular vein and connected to an externalized PM until the time of the re-implantation in PM dependent patients.
Complete success was defined as the successful removal of all the targeted leads and all lead material from the vascular space.1 Major complications were defined as outcomes that were life threatening, resulting in significant or permanent disability, procedure-related deaths, or required surgical intervention.1 Minor complications were defined as events related to the procedure that required medical intervention or minor procedural intervention. 1