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A conversation with Dr. Roger Freedman on lead extraction


 

Dr. Roger Freedman, University of Utah Health, recently sat down with Cook Medical to discuss his experiences using the femoral approach with the Needle’s Eye Snare®.

 

Q. How long have you been using the femoral approach as your primary extraction approach?

A. I’ve been using a femoral approach essentially from the time I started extractions over 20 years ago.

Q. How/why did you begin to use femoral as a primary approach to extraction?

A. I felt I had more control of the leads targeted for extraction when I approached them from the femoral vein. Also, in general, the leads could be extracted with less force from below than from a superior approach. You just weren’t fighting scar tissue all the way.

Q. What are your techniques for learning about and using the Needle’s Eye Snare?

A. A novice can get some idea of how the Needle’s Eye Snare works from just handling it and trying to snare a lead ex vivo. But the best way to really learn the technique is to watch cases, either in person or videos of cases.

Q. How do you train staff on preparing for each procedure using a femoral as a primary approach?

A. The key to successfully preparing for a case is consistency: consistency of procedural room location, anesthesia, TEE (transesophageal echocardiography), prep/drape, art line, blood products, adequate personnel each with a defined role, and surgical back-up. Once a few staff members are trained, they can train the rest of the staff as well as new staff joining the team.

Q. How do you train fellows on the femoral approach?

A. Like most skills that electrophysiology fellows learn to master, training consists of observing a skilled proceduralist and then gradually taking on increasingly complex hands-on maneuvers. And, of course, constructive criticism from mentor to trainee during and after cases is key. There should also be a thorough discussion of each case before it starts: the goals of the extraction, anticipated areas of difficulty, etc.

Q. What are some of the safety benefits when snaring the lead femorally, such as avoidance of the superior vena cava and removing traction from the heart wall?

A. The femoral approach gives you control of the lead that is so much better than just having a locking stylet in place. With traction on the lead from below there is an infinitely better “rail” than is provided with just a locking stylet. The “rail” is so good you can often make substantial progress along the lead from above with just the outer Evolution® RL sheath or the SteadySheath®, especially in the critical SVC (superior vena cava) area. This, along with being able to pull the lead away from the lateral wall of the SVC, allows for avoidance of SVC tear.

Q. What are the common challenges when using the Needle’s Eye Snare, and how do you overcome them?

A. The largest challenge, of course, is successfully snaring the lead. I advocate a systematic approach that starts with finding the segment of the lead that you can “bump” by rotating the snare next to the lead. The next steps are then draping the snare over the lead, sticking out the threader, and confirming that the lead is trapped between the snare and the threader.

Q. Why do most physicians only use a femoral device in a “bailout” scenario? How can this perception be overcome?

A. The best way to learn to successfully utilize femoral extraction tools is to use them as part of the initial approach on a regular basis. When doing so, there is time and circumstances to use the tools methodically. If you only use the femoral tools for “bailout” after a failed superior approach, your target lead is likely to have lost all its slack and be much harder to snare, your patient may not be stable, and you and your staff are likely to be tired and impatient.

Q. Why do you think the femoral approach is not utilized more?

A. With the superior approach, there is the intuitive appeal of being able to manually hold the lead and direct the sheath to (hopefully) track over the lead. Seems simple and often works. Slam-bang done, most of the time anyway. Whereas the femoral approach requires achieving some dexterity in maneuvering the Needle’s Eye Snare. Moreover, if the intravascular portion of the lead is to be removed out through the femoral vein, there’s always some hesitation before cutting the lead in the pectoral area and losing manual control of it. The femoral approach often takes more time and requires more hands-on personnel.

Q. Do you utilize this approach from the right internal jugular?

A. Yes, occasionally when femoral access is limited (IVC filter, thrombosed femoral veins, etc.) or sometimes when you need a better vector of force to disengage a lead from the right ventricle apex.

Q. What would you say to someone interested in using this approach more?

A. Come watch a case or two with a skilled operator!

About the Needle’s Eye Snare

The Needle’s Eye Snare is the only device indicated for femoral lead extraction. Enabling clinicians to efficiently and safely perform lead extraction procedures while helping to avoid common areas of complication.

When used as a primary approach for lead extraction, the Needle’s Eye Snare resulted in clinical success in 98.2% of patients, with a major complication rate of 0.7% and no procedural mortality.1

The versatility of the Needle’s Eye Snare allows for it to be used in a number of clinical scenarios, including as a primary approach when a lead is fixed at both ends or with a free distal tip, as well as for broken leads that would be unable to be extracted through the superior vessels.

Dr. Freedman is a paid consultant of Cook Medical.

References

  1. Frank A. Bracke, Lukas Dekker, Berry M. van Gelder, The Needle’s Eye Snare as a primary tool for pacing lead extraction, EP Europace, Volume 15, Issue 7, July 2013, Pages 1007–1012.