Successful percutaneous retrieval of an embolized helix from the hepatic vein during transvenous lead extraction

Key Teaching Points.

• •Complications in Lead Extraction: Transvenous lead extraction (TLE) procedures can result in significant complications, such as the embolization of lead fragments. In this case, the active helix of an ICD lead embolized to the hepatic vein during extraction, underscoring the need for careful management and preparation for potential complications.
• •Multidisciplinary Approach: The successful retrieval of the embolized helix from the hepatic vein illustrates the importance of a multidisciplinary team approach, involving interventional cardiologists, radiologists, and vascular specialists. This collaboration is crucial for managing complex cases and ensuring patient safety and positive outcomes.
• •Use of Specialized Equipment and Techniques: The case emphasizes the utility of specialized equipment, such as the 10mm Amplatz Goose Neck micro snare and steerable sheaths, in retrieving embolized lead fragments. Proper equipment and technical proficiency are essential for managing complications during TLE.
• •Infection Management in Cardiac Device Procedures: The case highlights the critical role of infection management in patients with cardiac devices. The decision to retrieve the embolized helix was influenced by the presence of an active infection, indicating that removing foreign materials from the body can be vital to prevent further complications and ensure effective infection control.

Introduction

A 79-year-old male patient with a complex cardiac history, including ischemic heart disease, a prior myocardial infarction, and multiple cardiac device implantations, presented with an infected and eroding cardiac device pocket. Because of this infection, percutaneous lead extraction was necessary. The procedure, performed using general anesthesia in a hybrid theatre, involved laser lead extraction. A complication arose when the implantable cardioverter defibrillator (ICD) lead helix embolized to the hepatic vein, requiring percutaneous retrieval. Postoperatively, the patient recovered well, underwent treatment with antibiotics for Staphylococcus epidermidis, and successfully received a new cardiac resynchronization therapy (CRT) device without further issues.

Case Report

A 79-yearold man was admitted to our institution for percutaneous lead extraction. The patient had a history of ischemic heart disease with prior myocardial infarction in 2002 with resulting left ventricle (LV) aneurysm for which he underwent coronary artery bypass grafting and LV aneurysm resection with placement of a left-sided dual-chamber ICD owing to ventricular arrythmias. He had a history of atrial arrythmias and of undergoing atrial fibrillation and flutter ablation. In 2015, he developed an ICD pocket infection requiring complete percutaneous extraction and subsequent right-sided CRT device with an active fixation single-chamber Durata ICD lead (Abbott Medical, Sylmar, CA) to the RV apex (Abbott) an active fixation Tendril atrial lead (Abbott) and a Quartet quadripolar LV lead (Abbott). In 2022, he underwent CRT device generator change for battery depletion.

In December 2023, he presented with a pocket infection and device erosion, and he was referred to our institution for lead extraction (Figure 1). The procedure was performed in our hybrid theatre using general anesthesia. Ultrasound-guided access of the femoral veins was performed with a 12F sheath to the right femoral vein and two 6F sheaths to the left femoral vein and right femoral artery. A temporary pacing wire was inserted to the right ventricle (RV) apex owing to pacing dependency, and a 0.35 Amplatz wire and Bridge Balloon (Philips, Drachten, the Netherlands) were introduced to the superior vena cava (SVC) and then parked in the inferior vena cava (IVC). The pocket was opened and debrided with the presence of purulent material. The leads were prepared with lead locking device locking (Phillips) stylets. The CS lead was unable to accept an lead locking device stylet. A 16F laser sheath (Philips) was prepared and inserted with no outer sheath because of the right-sided acute angulation of the axillary–SVC junction. The ICD lead was extracted first and the helix was retracted. Next, and a 16F laser sheath was used, and the lead was freed from the RV. As the lead was being retracted into the laser sheath, the helix appeared to catch on the vascular angulation. When attempting to retract the helix into the laser sheath, it elongated further and detached from the lead, embolizing to the right atrium (Figure 2). The right atrium and LV leads were then extracted with the 16F laser sheath. A temporary externalized lead was placed via the laser bore and inserted into the RV apex. The pocket was washed with betadine, and a VVI device was attached to the lead and externalized on the chest. Layered closure of pocket was performed with a Redivac drain placed to the wound.

Figure 1.

Erosion of right-sided cardiac resynchronization therapy device owing to infection at wound site with lead collar protrusion through skin.

Figure 2.

Fluoroscopic images of lead extraction and helix removal. A: Helix intact after being freed by laser sheath. B: Helix appears to catch during retrieval into the laser sheath. C: Right ventricle (RV) implantable cardioverter defibrillator lead helix elongates with traction. D: Helix detaches from the DF4 RV lead, but it appears to remain caught at the distal end. E: Implantable cardioverter defibrillator Helix floating free in the superior vena cava and right atrium (RA) during RA lead extraction. F: Cardiac resynchronization therapy device RV lead helix visualized in the hepatic vein. G: A 10-mm goose neck snare captures the lead fragment. H: Capture and retraction of lead fragment.

At this stage, we proceeded to remove the helix from the right atrium with femoral snaring, but it was noted on fluoroscopy to no longer be intracardiac, and it had embolized to the hepatic vein. In view of the history of infection and the fact that it could cause hepatic damage, we elected to remove the helix from the hepatic vein percutaneously with the assistance of our vascular team. The indwelling right femoral vein 12F sheath was used for access, and a 7F TourGuide (Aptus sheath - Medtronic, Galway, Ireland) steerable sheath was used to access the right middle hepatic vein. The catheter was advanced to the embolized lead fragment, and a 10-mm Amplatz Goose Neck micro snare (EV3) was used to snare the distal portion of the RV lead helix (Figure 3). The fragment was captured and retracted through the 7F TourGuide sheath, exiting the body without complication (Figure 4). The patient did well postoperatively. Tissue samples grew Staphylococcus epidermidis, which was treated with intravenous flucloxacillin. After 1 week, a new CRT device was implanted on the left side without complication, and the patient was discharged and remains well at the routine follow-up.

Figure 3.

Lead helix snared and withdrawn through the right femoral vein.

Figure 4.

Helix after rescue. Comparison to a 2.5 mL Luer Lock syringe.

Discussion

Lead fragment embolization is a potentially life-threatening complication associated with transvenous lead extraction (TLE).¹ The risk of lead breakage can be mitigated by the use of a locking stylet passed distally. Usually in cases of lead fragmentation, the distal lead tip remains embedded in the myocardium. Distal embolization is a rarely reported phenomenon, but it has been described with embolization to the pulmonary circulation and other vascular structures.² Embolization of a broken lead helix to the hepatic vein has been described previously in a 9-year-old Medtronic Sprint Quattro defibrillator lead presenting with lead fracture.³ During TLE, the active helix of the ICD lead embolized to a branch of the mid-hepatic vein, but removal of the lead fragment was not attempted because of the difficulty in reaching the distal hepatic vein using the available snaring equipment. At 12-month follow-up, there were no complications as a result of leaving the fragment in place.

To our knowledge, the present case is the first description in which a helix that embolized to the hepatic vein was successfully removed percutaneously. In our case, we elected to remove the embolized helix, as there was evidence of active infection and therefore removal was believed to be indicated to reduce the risk of ongoing infection. There was also concern that the embolized helix may have posed a risk of hepatic damage in the future. The hepatic retrieval procedure was performed by our interventional and vascular radiologists, and this highlights the importance of multidisciplinary input in the setting of percutaneous lead extraction procedures to ensure an optimal outcome.