Elective Sternotomy With Fluoroscopic Guidance for the Removal of a Residual Implantable Cardioverter Defibrillator Lead: A Case Report and Literature Review

Figure 1. Chest X-ray (frontal view) showing two radio-opaque objects corresponding to the tips of the ventricular lead. The upper tip is projected over the left innominate vein (green arrow), and the lower tip is projected over the right ventricle (red arrow)

Figure 2. (18F)-FDG PET scan revealing pathological hypermetabolism and associated findings in cervicothoracoabdominal sections On PET scan with (18F)-FDG imaging in sagittal cervicothoracoabdominal sections, prior to tracer injection (A), retrosternal material is observed extending into the left subclavian region (proximal end of the ICD lead), projecting over the subclavian vein and left innominate vein. Additionally, hyperdense material (right ventricular lead tip) generates artifacts at the apex of the right ventricle. One hour after (18F)-FDG tracer injection (B), intense pathological hypermetabolism is noted in the left supraclavicular region along a muscular trajectory and retrosternally, extending into the left subclavian area near the innominate vein, likely of infectious origin. This is associated with linear pathological hypermetabolism involving the manubrium and sternal body (blue arrows), extending superiorly to a pathological median suprasternal cutaneous hypermetabolism and inferiorly to hypermetabolism below the sternal notch. It further extends intrathoracically at the level of the right ventricle, adjacent to the residual material (white arrow). FDG: fluorodeoxyglucose;…

Figure 3. (18F)-FDG PET scan showing pathological hypermetabolism in cervicothoracic sections On PET scan (18F)-FDG imaging in a transverse cervicothoracic section, showing pathological cutaneous hypermetabolism in the median suprasternal region (blue arrow), extending into the left subclavian area over the innominate vein, which also shows pathological hypermetabolism (black arrow) (A). This hypermetabolism extends anteriorly along the K1 arc and beneath the pectoralis muscle (orange arrow) (B). FDG: fluorodeoxyglucose

Figure 4. Echocardiogram image showing a non-dilated, non-hypertrophied left ventricle (LV), with an element at the base of the right ventricle (RV) compatible with a tip of an ICD lead (blue arrow) ICD: implantable cardioverter defibrillator

Figure 5. Intraoperative photo showing the extraction using forceps, aided by adequate exposure of the left subclavian region with a retractor, from the frayed and tangled wire (blue arrow) of the ventricular lead tip that was partially retained with its sheath inside the left innominate vein through a venotomy performed with an electric scalpel

Figure 6. Photo showing the ventricular lead tip with its sheath and tangled wires, deformed after successful extraction from the left innominate vein (A), along with surrounding infected mediastinal tissue and fragments of thrombosis (B). The specimen was placed in a sterile container for cytobacteriological and histopathological studies

Figure 7. Intraoperative image during the second stage of surgery under cardiopulmonary bypass (CPB) with clamping, showing a right atriotomy to begin the extraction of the ventricular lead embedded in the muscular wall through the posterior pillar at the inferior wall level, following radiographic localization

Figure 8. Intraoperative fluoroscopic image of the right ventricle showing the ventricular lead tip (blue arrow), cut and embedded in its inferior wall, serving as a guide for surgical extraction

Figure 9. Intraoperative fluoroscopic image centered on the right ventricle, showing the cut ventricular lead tip inside the right myocardium, with the exposure of instruments serving as landmarks for surgical extraction (A), as well as the progression of the forceps through the endocardium before grasping the lead (B)

Figure 10. Intraoperative photo showing the tip of the right ventricular lead (red arrow) after its extraction, following fluoroscopic localization

Figure 11. Postoperative day 7 chest X-ray showing the disappearance of the material at both the level of the innominate vein and the right ventricle, as well as the regression of the left pleural effusion