DISCUSSION
Previous studies have shown that incorporating the femoral approach in
addition to the superior approach results in a higher rate of complete
procedural success during TLE.3,5 Furthermore, the
femoral approach is favored as the primary approach and is associated
with the successful advancement of a powered sheath through the superior
approach. The technique for grasping leads with inaccessible ends via
the femoral approach currently involves the use of an
NES.3 When the NES is not coaxially aligned with the
lead, the NES is ineffective for capture. We recommend against the
prolonged use of the NES during combined superior and femoral approach
lead extraction because excessive attempts may increase the risk of
atrial injury.4Our proposed Wire TRUST technique
enables a combined superior and femoral approach for TLE, even when the
lead tip is difficult to free owing to severe adhesion. Additionally,
this technique offers a safer and quicker alternative to the NES (Figure
3).
In Wire TRUST technique, there are two procedures to pass the 0.014-inch
guidewire through the ONE Snare. The first procedure involves passing
the 0.014-inch guidewire that has crossed the V lead through the snare
in the IVC. Aligning the snare system coaxially with the 0.014-inch
guidewire in the IVC is easier than aligning it in the RA, making
passing the wire through the snare easier. Manipulating the 0.014-inch
guidewire while keeping the pigtail catheter hooked to the V lead makes
passing the wire through the snare easier because of improvement of
operability of the 0.014-inch guidewire. Inserting a 0.035-inch
guidewire into the pigtail catheter causes the pigtail portion to
stretch and may release the hook on the V lead. Therefore, a 0.014-inch
guidewire is essential for this technique.
The second procedure involves passing both ends of the wire through the
snare outside the body after externalizing the 0.014-inch guidewire. The
advantages of the Wire TRUST technique are low difficulty and safety.
This technique is less difficult
than using the NES because the pigtail catheter is softer and has better
operability. A previous report showed the usefulness of a pigtail
catheter for retrieving catheter fragments with inaccessible free
ends.6 The safety of the Wire TRUST technique depends
on which type of 0.014-inch guidewire is used. The 0.014-inch guidewire
used for the Wire TRUST technique lacks sharp angles, similar to a NES,
thereby suggesting a reduced risk of myocardial injury (Figure 2).
Regarding the type of 0.014-inch guidewire, we consider the Nitinol
guidewire (not stainless) to be safe because it has shape memory and
does not have many sharp edges in the area where it grips the lead
(Figure 2K).
Simultaneously inserting a 4Fr pigtail catheter and a 6Fr snare catheter
is necessary. Therefore, a large-diameter sheath of ≥10Fr would
theoretically be required for this technique (a 14Fr sheath was used in
this case). Moreover, because of externalization of the 0.014-inch
guidewire, manipulating the guidewire by pushing and pulling to adjust
the position where the lead is held by the snare is easy (see
Supplemental Video).
If the lead becomes free at the distal end during the procedure,
continuing with the superior approach while holding the lead with the
Wire TRUST technique or attempting to grasp the lead again from the
distal end using the ONE Snare is possible. Therefore, the lead
extractor should become familiar with this technique described here for
safe TLE.
Conclusions
To the best of our knowledge, this is the first report of our novel Wire
TRUST technique to grasp a lead with inaccessible ends and facilitate
powered sheath advancement via the superior approach.