Journal of Arrhythmia 31 (2015) 249–251
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Successful transjugular extraction of a lead in front of the anterior scalene muscle by using snare technique Ayako Okada, MDn, Kazunori Aizawa, MD, Takeshi Tomita, MD, Kouji Yoshie, MD, Takahiro Takeuchi, MD, Morio Shoda, MD, Uichi Ikeda, MD Department of Cardiovascular Medicine, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, Nagano 390-8621, Japan
art ic l e i nf o
a b s t r a c t
Article history: Received 30 August 2014 Received in revised form 26 November 2014 Accepted 10 December 2014 Available online 17 January 2015
The incidence of cardiovascular implantable electronic device infection is increasing. We report a case of and successful device removal in a 79-year-old man with implantable cardioverter-deﬁbrillator infection. Right phrenic nerve paralysis was evident on chest radiography. The lead was in front of the anterior scalene muscle, close to the left phrenic nerve. Therefore, extraction carried a risk of bilateral phrenic nerve paralysis. The lead was successfully extracted from the right internal jugular vein by using the snare technique. No complications occurred, and the extraction was successful. & 2014 Japanese Heart Rhythm Society. Published by Elsevier B.V. All rights reserved.
Keywords: Lead extraction Phrenic nerve paralysis Snare technique
1. Clinical case The worldwide estimated prevalence of cardiovascular implantable electronic device (CIED) infection is 1–2%. Prompt removal of infected devices ensures survival [1–4]. We report successful extraction of a lead from an infected CIED by using an excimer laser system. A 79-year-old man developed diastolic cardiomyopathy, with congestive heart failure onset, and was admitted to hospital for insertion of a dual-chamber implantable cardioverter-deﬁbrillator in 2004. The operator intended to insert the atrial lead into the cephalic vein, but inserted it into a branch of the cephalic vein. Generator exchange was performed in 2011. One month later, swelling and erythema appeared at the device pocket. Stab culture was positive for methicillin-resistant Staphylococcus epidermidis. Antibiotics were administered, and the generator was removed. However, the pocket infection recurred. He was transferred to our hospital for device removal . The ventricular lead had been inserted via the left subclavian vein via extrathoracic puncture. The atrial lead was inserted in the vein running in front of the left phrenic nerve and the anterior scalene muscle, through the left jugular vein to the innominate vein [Figs. 1 and 2]. Because of the close proximity of the lead to the left phrenic nerve, injury to the nerve was a concern. Right
phrenic nerve paralysis was evident on chest radiography. As lead extraction from the supraclavicular fossa is associated with bilateral phrenic nerve paralysis, we chose to have the atrial lead fall into the inferior vena cava and then to extract it from the right jugular vein using the snare technique . The procedure was performed under general anesthesia by a cardiovascular surgeon in an operating room. After debriding and
Corresponding author. Tel.: þ 81 263 37 3191; fax: þ 81 263 3195. E-mail addresses: [email protected]
(A. Okada), [email protected]
(K. Aizawa), [email protected]
(T. Tomita), [email protected]
(K. Yoshie), [email protected]
(T. Takeuchi), [email protected]
(M. Shoda), [email protected]
Fig. 1. Chest radiography showing right phrenic nerve paralysis.
http://dx.doi.org/10.1016/j.joa.2014.12.002 1880-4276/& 2014 Japanese Heart Rhythm Society. Published by Elsevier B.V. All rights reserved.
A. Okada et al. / Journal of Arrhythmia 31 (2015) 249–251
Fig. 2. (a) Computed tomography image showing the location of the lead. Yellow line indicating the putative location of the phrenic nerve. (b) Computed tomography image showing the lead (open arrow) and the left anterior scalene muscle (closed arrow).
Fig. 3. (a–d) Temporal-sequence ﬂuoroscopic images showing: (a) the proximal stamp of the atrial lead falling by insertion of the ablation catheter through the right femoral vein, (b) the proximal end of the lead caught by a snare catheter, (c) the proximal edge of the lead drawn from the right jugular vein, and (d) the laser sheath introduced and advanced over the lead, overcoming binding sites to the distal tip.
cutting the lead, we drew the proximal atrial stamp to the supraclavicular fossa. We conﬁrmed that the atrial lead glided inside the adherences by pushing the lead with a stylet inside and concluded that the proximal stamp of the atrial lead could be drawn from the right internal jugular vein. Generally, strong adhesion is present at the superior vena cava (SVC) coil portion; therefore, we removed the atrial lead ﬁrst. The ablation catheter was used to allow the proximal stamp of the atrial lead to fall into the inferior vena cava from the right femoral vein. The lead was
then removed through the right jugular vein using a snare catheter. A locking stylet was advanced into the lead tip. A 12-Fr laser sheath was advanced to the atrial lead and the lead was extracted successfully [Fig. 3]. Another locking stylet was advanced into the ventricular lead tip. A 14-Fr laser sheath was advanced into the left subclavian vein, with the ventricular lead inside. There was strong adhesion at the puncture site and SVC coil portion; several removal attempts were unsuccessful due to the tenacious adhesions; therefore, a 16-Fr laser sheath was used. After a few
A. Okada et al. / Journal of Arrhythmia 31 (2015) 249–251
bursts, the distal tip of the lead was freed and collected inside the laser sheath.
Funding No funding was received for this study.
2. Discussion Excimer laser sheaths have proved safe and effective for the extraction of leads from an infected CIED [1–5]. Lead extraction with and without an excimer laser system has shown extraction rates of 95% and 64%, respectively. The rate of serious lead extraction-related complications (superior vena cava laceration, severe cardiac tamponade, and massive pulmonary embolism) is approximately 1% [4,5], and death-related injury rates are o1% . Invasive manipulation around the subclavian vein can cause phrenic nerve paralysis leading to respiratory dysfunction and death . The phrenic nerve runs in front of the anterior scalene muscle; a hematoma of the anterior scalene muscle can cause severe phrenic nerve paralysis. However, no cases of phrenic nerve paralysis due to excimer laser lead extraction have been reported. This case was rare due to the location of the atrial lead and paralysis of the right phrenic nerve . Bilateral phrenic nerve paralysis had to be avoided. Furthermore, the patient's respiratory function was poor. If bilateral phrenic nerve paralysis had occurred, it could have been fatal, and it would have been difﬁcult to wean the patient off the ventilator. Therefore, much care should be taken. Although we decided that transjugular extraction of the atrial lead was the safest method, this method warrants further discussion. Ethics Written consent was obtained from the patient to publish the details of the present case.
Conﬂicts of interest None declared.
Acknowledgments The authors wish to express their deepest appreciation to Prof. Shoda and Prof. Ikeda for their thoughtful advice and guidance. References  Kennergren C, Bucknall CA, Butter C, et al. Laser assisted lead extraction: the European experience. Europace 2007;9:651–6.  Jastrzebski M, Bacior B, Wojciechowska W, et al. Left ventricular lead implantation at a phrenic stimulation site is safe and effective. Europace 2011;13:520–5.  Sanchez-Quintana D, Ho SY, Climent V, et al. Anatomic evaluation of the left phrenic nerve relevant to epicardial and endocardial catheter ablation: implications for phrenic nerve injury. Heart Rhythm 2009;6:764–8.  Mulpuru SK, Pretorius VG, Birgersdotter-Green UM. Device infections: management and indications for lead extraction. Circulation 2013;128:1031–8.  Okamura H, Yasuda Y, Sato S, et al. Initial experience using excimer laser for the extraction of chronically implanted pacemaker and implantable cardioverter deﬁbrillator leads in Japanese patients. J Cardiol 2013;62:195–200.