Transvenous lead extraction: The subclavian-to-jugular pull-through technique

Figures

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  Figure 1. A: The chest radiograph demonstrating the position of the targeted leads. B: The locking stylet only advanced as far as the shock coil, where it was deployed. The lead was withdrawn into the outer sheath of the Needle’s Eye Snare (Cook Medical). C: The Needle’s Eye Snare held the shock lead taut in the right atrium, providing countertraction as the Evolution RL sheath (Cook Medical) dissected down to the snare without difficulty. D: The lead coil de-spiraled after its release from the snare, halting progress of the dissecting sheath.

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  Figure 2. A: After right jugular vein access was gained, a Gooseneck snare (blue star) was used to grasp the 0.032 guidewire positioned in the superior vena cava from the subclavian access and pull it out through the jugular vein sheath. B: An SL0 sheath was advanced over the 0.032 guidewire from the jugular to the subclavian, where it emerged. C: The Gooseneck catheter was passed through the SL0 to exit at the subclavian access where the locking stylet was directed into it as far as possible; retracting the Gooseneck catheter pulled the locking stylet and lead (white arrow) into the SL0 (black star). D: The SL0, with the lead and locking stylet engulfed within it, was retracted back at the jugular, where it all surfaced. E: With a straightened railroad from the jugular, the rotational dissecting sheath was advanced to the lead tip to dissect the tip free and exert counter-pressure to complete the extraction. F: The extracted lead and locking stylet, demonstrating the unraveled coil.

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  Figure 3. A: A Gooseneck snare from the right jugular vein was used to grasp the 0.032 guidewire (red) parked in the superior vena cava from the subclavian access, which was preserved using the outer sheath of the dissecting tool. The wire was pulled out through the jugular vein sheath (yellow). B: An SL0 sheath (green) was advanced over the 0.032 guidewire from the jugular to exit at the subclavian access. C: The SL0 sheath behaves as a “tunnel” connecting the subclavian and jugular access points. The free handle of the locking stylet was directed into the exposed SL0 sheath. D: The locking stylet handle emerged at the jugular end, which was used to pull the whole of the stylet and attached lead into the SL0 at the subclavian; no metal was exposed in the vasculature. E: The SL0, with the locking stylet and lead engulfed within it, was retracted back at the jugular, where it all surfaced. F: The rotational dissecting tool (black) was advanced successfully over the straightened railroad from the jugular, to complete the extraction.