Asian Cardiovasc Thorac Ann 2002;10:69-71
© 2002 Asia Publishing EXchange Pte Ltd
Percutaneous Extraction of Entrapped Infective Transvenous Pacing Lead
Rizwan Aziz Memon, FRCS,
John Buckley, FRCR,
Angus O'Donnell, FRCS
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Departments of Cardiothoracic Surgery and Radiology Cork University Hospital Cork, Republic of Ireland
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Rizwan Aziz Memon, FRCS Tel: 353 1 410 3000 Fax: 353 1 410 3549 email: rizwanazizmemon{at}hotmail.com Flat No. 40, 38 Newcomen Street, London SE1 1YZ, UK.
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ABSTRACT
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A 57-year-old woman had an entrapped infected transvenous pacing lead successfully removed percutaneously with a Dormier basket under fluoroscopy, thus avoiding a major surgical procedure.
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INTRODUCTION
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Infection, although uncommon, can be the most lethal of all potential complications following transvenous pacemaker implantation, and it constitutes an absolute indication for complete removal of the implanted hardware to eradicate infection.1 Until recently, if an infected lead became trapped, it could only be retrieved by a thora-cotomy or sternotomy with or without cardiopulmonary bypass.2,3
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CASE REPORT
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A 57-year-old woman with symptomatic bradycardia had undergone permanent pacemaker insertion with an atrial lead passed through the right subclavian vein and the generator box placed in the right pectoral region. She had been well for 13 years before requiring generator box replacement (Figure 1
). A replacement generator box was attached to the original right atrial lead. An infection of the pacemaker pocket developed and persisted even after multiple courses of antibiotics as well as incision and drainage of the pocket abscess. Therefore, it was decided to replace the whole system. After inserting a temporary pacing wire via the femoral vein, the generator box was explanted, but the right atrial pacing lead was found to be trapped. The lead was cut short and left in situ, and the wound was debrided, irrigated, packed with Betadine wick, and subsequently closed in layers. This was carried out under appropriate antibiotic cover. As soon as the patient became afebrile and inflammatory markers were back to normal, a rate-responsive pacemaker was inserted through the right internal jugular vein, the lead was tunneled from a neck puncture site over the clavicle to the box that was placed in a pocket as distant as possible from the previously infected site (Figure 2). The left internal jugular vein had been approached first but the wire passed into the coronary sinus, suggesting a persistent left-sided superior vena cava.
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Figure 1. Chest radiograph showing the old pacing box in situ with the pacing lead passing through right subclavian vein.
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Figure 2. Chest radiograph showing the new pacing box in situ with the pacing lead passing through right internal jugular vein, and the old lead entrapped in the subclavian vein.
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Four weeks later, the patient presented again with a discharging sinus over the site of the original pacemaker wire; the new pacemaker system was working well. The infected wound was reexplored, the abscess cavity was drained after thorough irrigation, and another course of antibiotics was commenced. As she remained unwell, it was decided to remove the original pacing lead. To avoid a major surgical procedure, the possibility of using a Dormier basket (Cook Vascular, Inc., Leechburg, PA, USA) was suggested. Informed consent was obtained and with cardiothoracic surgical backup, the procedure was carried out in the catheter suite under local anesthesia. The diameter and length of the Dormier basket is crucial and it should be selected according to the size of the target (entrapped lead) and the height of the patient. The Dormier basket was introduced into the right femoral vein over a guidewire (Seldinger technique) and advanced into the right atrium under fluoroscopy. The tip of the entrapped pacing lead was easily caught and retrieved without much manipulation. The new pacing system was not disturbed (Figure 3). After removal of the infected lead, recovery was rapid and uneventful, and the patient was discharged within a few days. On follow-up, she remained asymptomatic.
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Figure 3. Chest radiograph after successful removal of the entrapped subclavian lead. The new pacing system is undisturbed in situ.
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DISCUSSION
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Within a few months of implantation of a transvenous pacemaker system, a fibrous sheath forms along the course of the transvenous lead, making percutaneous withdrawal difficult, sometimes impossible, in approximately 5% of cases. In this situation, forceful extraction may cause lifethreatening arrhythmias, avulsion of fragments of the right ventricle, right atrial appendage, or tricuspid valve, and cardiac tamponade.1 Thus, many practitioners advocate abandoning uninfected inactive leads after affixing the free end to underlying soft tissues. Long-term follow-up has documented the safety of such an approach.4
Infection of a transvenous pacemaker is a rare (1% to 3%) but serious complication that can be lifethreatening due to septicemia, endocarditis, or pulmonary emboli, and it requires complete withdrawal of the implanted device.1,5 Surgery offers the most direct and, therefore, the most controlled method of removing entrapped leads. Various surgical approaches including thoracotomy and median sternotomy with or without cardiopulmonary bypass, deep hypothermic circulatory arrest, and open surgical exploration of the superior vena cava and innominate vein have been described.6 However, these surgical options are not free from potential complications; thus the possibility of less invasive approaches as in this case should be explored first. Open surgery should be reserved for the more complex cases.
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REFERENCES
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Madigan NP, Curtis JJ, Sanfelippo JF, Murphy TJ. Difficulty of extraction of chronically implanted tined ventricular endocardial leads. J Am Coll Cardiol
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Klug D, Lacroix D, Savoye C, Goullard L, Grandmougin D, Hanniquin JL, et al. Systemic infection related to endocarditis on pacemaker leads: clinical presentation and management. Circulation
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ABSTRACT
INTRODUCTION
