EXTRACTION PROCEDURE
All TLE procedures were performed by experienced cardiac electrophysiologists with a cardiothoracic surgeon immediately available on-site and chest and abdomen prepared for emergency sternotomy. Patients underwent general anesthesia with hemodynamic monitoring, and a transesophageal echocardiography probe was available in the room. A large-bore femoral venous access was inserted in all patients in case a diversion to femoral setting extraction will be needed.
A stepwise approach was used in all patients as follows: in the pre laser era (July 2010 -December 2011) simple traction was applied to the lead from the pocket, usually after introduction of locking stylet. If still unsuccessful, at least one of the following mechanical tools was used: Evolution RL Controlled-Rotation Dilator Sheat, Teflon or Polypropylene Byrd Dilator (both from Cook Medical, Bloomington ,IN), stainless steel dilator, and electrosurgical dissection (EDS) sheath (Cook Vascular Incorporated, Vandergrift, PA, USA). When laser sheaths (GlideLight Laser Sheath - Spectranetics, Colorado Springs, CO) were introduced at our institution it became a second option after simple traction. Tight Rail (Spectranetics, Phillips, Colorado Springs, CO), was later introduced during 2016 and became an alternative second option.
In cases where the superior approach was not fully successful and no major complication had occurred, femoral approach was attempted during the same procedure. In these cases, using the femoral vein access acquired earlier, a Needle’s Eye Snare Retrieval (Cook Medical, Leechburg, Pennsylvania), a Gooseneck snare (ev3, Europe SAS, Paris ,France) or a deflectable ablation catheter were deployed to catch the lead or remanents and extract from the femoral vein. Femoral approach was not implemented as a combined technique with the superior approach, nor was it used to rail the lead in case of laser and power tools usage.
The TLE procedure was terminated after complete removal of the leads; when lead fragments could not be further removed or in the event of a major complication.