Device Upgrade: When Should we Extract / Abandon? Bryan Baranowski, MD Staff, Cleveland Clinic Section of EP and Pacing
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1 Device Upgrade: When Should we Extract / Abandon? Bryan Baranowski, MD Staff, Cleveland Clinic Section of EP and Pacing CRT Follow-uo Considerations l March 2013 l 1
2 Occluded Subclavian / Innominate Vein
3 Lead associated Axillary / Sub-Clavian / Innominate Stenosis Lead associated stenosis is not uncommon Venography in 100 consecutive patients undergoing lead addition: 26% of patient with Stenosis > 70% 9% with complete occlusion Europace 9(5): , 2007.
4 Management Options? Are all leads functional? No Is it preferred to remove the non-functional hardware? Risks of extraction / removal versus Consequences of abandoned hardware
5 Mechanical Extraction with Retained Guidewire Access: Complications: SVC tear Subclavian / innominate vein tear (mediastinal bleed / hemothorax) AV Fistula Functional lead dislodgement / damage
6 Running the Gauntlet: Subclavian Vein
7 Running the Gauntlet: Subclavian Vein
8 Running the Gauntlet: Subclavian Vein
9 Running the Gauntlet: Subclavian Vein
10 Running the Gauntlet: Subclavian Vein Cronin EM et al. Heart Rhythm Mar;11(3):419-25
11 Running the Gauntlet: Subclavian Vein Cronin EM et al. Heart Rhythm Mar;11(3):419-25
12 Running the Gauntlet: Innominate Vein
13 Running the Gauntlet: Innominate Vein
14 Running the Gauntlet: Innominate Vein
15 Running the Gauntlet: Innominate Vein
16
17 Running the Gauntlet: Innominate Vein
18 Running the Gauntlet: Innominate Vein
19 8 AV fistulas occurring in 2471 extraction procedures from 2001 to 2012 (0.3% of procedures) 3 left subclavian vein to LIMA 3 Innominate vein to brachiocephalic artery 1 Innominate vein to aorta 1 left subclavian vein to left subclavian artery Cronin EM et al. Heart Rhythm Mar;11(3):404-11
20 Management Options? Are all leads functional? No Is it preferred to remove the non-functional hardware? Risks of extraction / removal versus Consequences of abandoned hardware
21 Cardiac Implantable Electronic Device Infections Added Complexity and Suboptimal Outcomes With Previously Abandoned Leads 1386 consecutive patients undergoing extraction, 323 (23%) had abandoned leads Failure to achieve complete extraction without a major complication occurred more frequently in patients with abandoned leads (13.0 vs. 3.7%, p<0.0001) Hussein et al. J A C C : EP VOL. 3, NO. 1,
22 Cardiac Implantable Electronic Device Infections Added Complexity and Suboptimal Outcomes With Previously Abandoned Leads Major and minor procedural complications occurred more frequently in patients with abandoned leads: Major 3.7 vs. 1.4%, p=0.009 Minor 7.7 vs. 4.4%, p=0.02 Hussein et al. J A C C : EP VOL. 3, NO. 1,
23 Management Options? Are all leads functional? Yes Options to consider: 1. Cross occlusion with hydrophilic wire +/- catheter. Venoplasty as needed. 2. Puncture proximal to the site of occlusion 3. Tunnel from contra-lateral side
24 Management Options? Are all leads functional? Yes Options to consider: 1. Cross occlusion with hydrophilic wire +/- catheter. Venoplasty as needed. 2. Puncture proximal to the site of occlusion 3. Tunnel from contra-lateral side
25 Management Options? Are all leads functional? Yes Options to consider: 1. Cross occlusion with hydrophilic wire +/- catheter. Venoplasty as needed. 2. Puncture proximal to the site of occlusion 3. Tunnel from contra-lateral side
26 END?
27 Cardiac Implantable Electronic Device extraction: Impact of Abandoned Leads
28 Typically a viable option only when the lead is <1-2 years old. Lead addition in 373 consecutive patient with vein occlusion Venoplasty was successful in 371 of 373 patients 86% were crossed with a hydrophilic wire Microdissection / excimer laser were used to cross three of the four wirerefractory occlusions No Complications reported: Contrast extravasation was common. Balloon rupture was rare (3), and not clinically significant No damage to the existing leads No clinical complications Heart Rhythm 2011;8:
29 713 patients undergoing lead addition at the time of generator change or device upgrade Major complications: 2.4 % peri-procedure 14% at 6 months Circulation. 2010;122:
30 Management Options? No
Girish M Nair, Seeger Shen, Pablo B Nery, Calum J Redpath, David H Birnie
268 Case Report Cardiac Resynchronization Therapy in a Patient with Persistent Left Superior Vena Cava Draining into the Coronary Sinus and Absent Innominate Vein: A Case Report and Review of Literature
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Key Words: Balloon Venoplasty of Subclavian Vein, Cardiac Resynchronisation Therapy. Case report
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CLINICAL COMPENDIUM The HeartLight Endoscopic Ablation System Putting a New Level of PVI Precision Close at Hand CardioFocus.com Published results noted below may include references to both on-label and