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    • br Conclusion br Conflicts of

    2019-05-06


    Conclusion
    Conflicts of interest
    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 proton pump inhibitors list 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 [1]. 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 [2]. The procedure was performed under general anesthesia by a cardiovascular surgeon in an operating room. After debriding and 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 bursts, the distal tip of the lead was freed and collected inside the laser sheath.
    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 <1% [1]. Invasive manipulation around the subclavian vein can cause phrenic nerve paralysis leading to respiratory dysfunction and death [2]. 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 [3]. Bilateral phrenic nerve paralysis had to be avoided. Furthermore, the patient׳s respiratory function was poor. If bilateral phrenic nerve paralysis had occurred, neural tube 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.