Remotely observe a live lead extraction and learn from experienced extractors. This live recorded observation will highlight key aspects in lead extraction from pre-case planning to extraction strategy. Dr. Canby and Dr. Al-Ahmad will share best practices as they progress through the procedure and answer questions from the audience.
AMIN AL-AHMAD: Morning from Austin, Texas. We're here today with the live lead extraction education program hosted by Phillips Lead Academy. I'm Amin Al-Ahmad. I'm one of the cardiac electrophysiologist here, and my colleague Dr. Bob Canby, we're both going to be performing a lead extraction case for you. First, as we get started, I just wanted to, of course, say good morning to everybody here and all around the world. I know there's different time zones. And welcome to Austin, virtually. Hopefully, we'll be able to [AUDIO OUT] people again soon. I also want to shout out and say thank you to our lab staff here, who've done a really great job in terms of getting things set up on behind the scenes efforts, in terms of getting the audio and the visual and everything set up. So with that, we'll start. We've already done a little bit on this case and I'll explain to you what we've done so far, but let's go ahead and show you what this case is all about. So this is our patient. He's a 76 year old gentleman with a dual chamber pacemaker, a pacemaker put in 2008 for sinus node dysfunction. It's a scientific device. Device model is an S602. The A lead is a Boston A lead, model 4136, and the ventricular lead is a 4137. The right ventricular lead thresholds have increased over time. Now they're at over four volts and the device has reached the elective replacement interval. In addition to this, the patient needs MRIs for his back. So in discussing this with the patient, the discussion was, do you just accept it since his sinus node dysfunction and live with a poorly functioning V lead? Or if the lead fails, would you implant the new lead? In which case, you'd cap the old one and he wouldn't be MRI compatible anymore. Or do you extract? And so after discussions with the patient, the decision was to go ahead and extract the existing lead, or leads, and move forward with extraction. Go to the next slide. So in terms of this-- the way we view this, there's a pre-op assessment that has to happen. You have to think about what type of device it is-- ICD, BiV, all of those things. What are the number of leads that you're dealing with in the lead models? What are they? Are they active fixation? Are they passive fixation? Or are they extendable, retractable? And what was the date of implant? One of the things that's really, really critical here is to get the primary data because oftentimes, the patient doesn't know this or lost the card that came from the company. And oftentimes, the patient's moved or has been to other institutions so you won't have accurate data. You need to really make sure you know this so you're not surprised with leads that have been capped in the past, or epicardial leads, or things that you can't deal with. There are patient-related things in the history that you want to make sure of, co-morbid conditions, in particular. Things like diabetes, obesity, people who are really cachectic, or thin. Prior surgery's important to know, in particular. If you run into a problem, it's helpful for the surgeons to know what they're dealing with. And so these are the things you want to understand before you go forward. And then pre-op testing for these patients-- an echocardiogram, in my view, is important in particular, if you're going to reimplant somebody. If their EF is low, do you reimplant them with the same device? A different device? A chest X-ray to confirm what leads and where those leads are since, again, the patient may not always provide you with accurate information. Some people are doing CT scans in order to look at the course of the leads through the vasculature. We've not tended to do that much, but there has been some data suggesting that in doing that, you can see whether the leads might be extravascular in some situations. Now typically, before any of this, you have to document the indications of the procedure, the risks, and alternatives of procedure. This is really, really important in particular if you're doing something with a class II indication. A class I indication is very straightforward. A class II indication-- you want to make sure that you have the right reason to do it, and weigh all these types of reasons. An example would be if you have a superfluous lead that's 20 years old in a 90-year-old woman, it may not be a wise decision to extract it. Versus a superfluous lead, for example, in a 50-year-old might be something to consider. If it's a class I indication, again, document risks, alternatives, and everything. But in those cases, it's clear that the leads need to come out. As I mentioned earlier, as part of your pre-procedural planning, chest X-ray always. Know what leads you're dealing with. I can't tell you how important this is in the sense that, again, I've been in situations where leads have shown up that you didn't anticipate. You go into the room and suddenly, now there's three leads instead of two. Somebody capped a lead and nobody knew about it because of patients being from different centers, and so forth. And again, CT scan we mentioned earlier. When we do these procedures, it's important to observe the time out, if you will, and understand that you have all of your backup and everything set up the right way. We typically will have surgical backup, but it's important to know that you have all the appropriate equipment. Do the surgeons have everything they need in case something goes bad? Now, this fortunately doesn't happen very often, but if it does the difference of knowing where everything is and how to get everything can be the difference between a successful outcome or an unsuccessful outcome. You need to have defined roles for the staff in case of an emergency. Make sure everybody knows what they're going to do, how they're going to do it. And you need to respond quickly if something does happen. We'll type and cross. We'll have blood available for these procedures. That's very important if you do end up having a significant hemorrhage, then time is of the essence. Typically, in the groin we'll put in an arterial line. You can use an A line in the groin or in the arm. Typically, will use the groin just in case it needs to be used for [INAUDIBLE] later. Also, a high volume venous line for fluid resuscitation, typically also in the groin. So that's, always, what we do at our center here. You need to assess whether they need a temporary pacing catheter, so that's important. We'll typically image the lung fields pre-extraction, do a venogram if we're planning on reimplanting. And make sure how it looks on fluoroscopy, just in case you have bleeding and there's a hemothorax. Transesophageal echo or intracardiac echo during the procedure is important. And then lastly, our routine is placing a wire for a bridge balloon and on occasion, putting in the bridge balloon. We've already, in this case, have figured out where the bridge balloon would go. We've placed the wire up into what looks like the jugular vein. And the bridge balloon has already been advanced and we figured out where it is. We've marked the balloon so that we know how far to push it up, in case of an emergency. And then lastly, what's your strategy after you're done? That's also important to think of before. Do you really need to reimplant? Not every single patient who has an extraction needs a reimplant. It's important to reevaluate that patient, look at their initial indications. Do they still exist? And then if you're unable to implant them quickly-- for example, if they're bacteremic, you may consider something like a temporary pacing catheter or a permanent lead attached to an older device. Or in some cases, a leadless pacemaker can be used for these types of circumstances. So with that, I'm going to go ahead and join my colleague Dr. Canby. What we've done already is we've [INAUDIBLE] given access in the groin. I think Dr. Canby's already taken out the device and has dissected the leads out and is about to unscrew them. BOB CANBY: All right, I cannot hear anything from in here so-- [INAUDIBLE] What I'll do-- are we on? Do you want me to explain where I am right now? AMIN AL-AHMAD: Yeah, where are you with things now, Bob? BOB CANBY: Again, I'm Bob Canby. So the first thing-- and again, I'm sorry I didn't hear all the initial conversation, but we did shoot a venogram. Did you show the venogram, ground Dr. Al-Ahmad? AMIN AL-AHMAD: No, I did not. If you want to go ahead and show it, Matt-- BOB CANBY: Do you want to run that venogram? Before cases, I typically shoot a venogram to try to get an idea. We're a little bit low on here, but I think we can appreciate that there appear to be collaterals that are going North, so to speak. Very hard to tell whether there's any flow along the path of the subclavian. And then it sort of reconstitutes toward the midline. First thing I typically try to do, even before I access to pocket, is I'll try to get access into the subclavian. And I took a standard needle and, essentially, did a first rib approach down to those leads. When I got venous return, I used a Glidewire. And we should have some of the-- I think I did a fluorosave to try to pass this Glidewire through the area of the stenosis. You can tell the multiple collateral vessels-- AMIN AL-AHMAD: You can see, actually, on that fluorosave, there's also the bridge balloon being placed in the appropriate position. What do you-- this is a strategy that I've also used, is getting access before you do the extraction. And I think that one of the things that I've seen is that if you do the extraction first, sometimes it can-- especially if it's a tough extraction-- you can end up with thrombus in that vein, and make it really hard to get access. So I think that getting access before you get started makes a lot of sense. BOB CANBY: And I like to always maintain some options. If they're occluded and you can't obtain access, then you're going to be very reliant on, as you take out that lead, being able to retain access. And in some cases, inadvertently, if you lose that central access, you may not be able to get it back again. So getting access in the first place gives you that additional safety that you should very likely be able to reimplant if you're trying to stay on the ipsilateral side. AMIN AL-AHMAD: In terms of the leads, what do you look at in terms of lead models? And when you're using electrocautery, do the models matter to you? BOB CANBY: Yeah. For using-- lead models do make, actually, a fair amount of difference from several aspects of this case. The constructions of the leads are different. Some are more robust and have more tensile strength, and others are a little bit more friable. Some you can actually pull on relatively hard, others will start to unwrap. And so knowing the construction of the lead and what their tendency to do when you're trying to maneuver is important. We typically use a plasma-type blade when we're working with leads because we can actually apply energy down to the installation on the lead. In general, most pacemaker leads and most defibrillator leads have enough insulation that, most of the time, you don't have to worry too much about essentially burning into the insulation itself. But on some of the LV leads, particularly if they've been in them for a while, they're pretty thin on their insulation and you do have to be a little bit more careful. AMIN AL-AHMAD: Be a little cautious with those. So at this stage, we have-- the two leads are exposed, and have we put in a clearing stylet at this point yet? Or-- BOB CANBY: That's-- I was going to put the clearing stylets in now. AMIN AL-AHMAD: OK so this is our next step, is we're going to take a stylet and just clear the lumen of the lead. It also allows us to unscrew the lead at this point. BOB CANBY: So when we disconnect it from the pacemaker, the ventricular lead is the one I'm holding now. So we'll just go ahead and take a clearing stylet to the sound the integrity of that lead, and just sort of advance-- AMIN AL-AHMAD: And this is helpful because if you're going to end up-- you have to lock these leads in, and really having the ability to lock the whole lead makes a huge difference. If you're unable to get the locking stylet all the way down, it can be the difference being an easy case and a not so easy case. BOB CANBY: So this is a 60 centimeter lead and based on the length of the clearing stylet, I can tell you we're very close to the end, if we're not all the way out. You don't always get to see the clearing stylet, but I'm pretty convinced I'm close to the tip. So what I typically do is take a hemostat, clip on to the distal electrode port here. And then with that in, go ahead and rotate and see if that helix will retract. AMIN AL-AHMAD: And one of the things to note is that it takes a lot more turns to unscrew it if it's been in for a long time. When you screw these in early on at the implant time, it's only 10 or 11, 12 times you screw the lead in. But to unscrew the lead actually takes a lot more. BOB CANBY: So I get probably 15 turns or so but on this particular lead, it also tightens down the electrode around the locking stylet. Sometimes, the torque of trying to unscrew the helix doesn't actually transmit to the tip. I found that if you take the sounding stylet, and remove it, and push it back into place, sometimes it helps transmit that rotational torque down to the distal electrode. AMIN AL-AHMAD: Yeah that's a really good tip because you can over unscrew the lead, if you will. And end up-- in certain lead designs, you'll end up with a very tight lumen. And it'll make the rest of the extraction case more difficult. And again, if you give it several turns sometimes just waiting a little bit. And over time, that helix will work its way out. And in the end of the day, it's a balance. If you're unable to unscrew the lead completely, you may just have to go with what you have. BOB CANBY: This one appears that it did not completely retract, so we may be in that situation here. AMIN AL-AHMAD: Yeah. And again, the balance is, in this particular lead design, if you overdo that, it'll tighten up the central lumen. And that makes things worse because then you can't advance the locking stylet. It's far more important to advance a locking stylet than it is to undo the helix, in many cases. BOB CANBY: So I think this is a 53 centimeter atrial lead. Taking that into account, I think, again, we're going to be relatively close and we'll go through the same motions to see whether this atrial stylet will retract that helix. AMIN AL-AHMAD: You can see a little bit of motion on it, maybe. There it goes, perfect. BOB CANBY: So the atrial screw came back inside the lead. So-- AMIN AL-AHMAD: So after this, our next step is, essentially, to prep the leads for extraction. So get a heavy scissors and we'll go ahead and cut the leads here. BOB CANBY: So I cut the lead, took off the insulation. Another trick that I often do is I look down deep into the pocket as I'm preparing the leads, just to make sure that the original implanter didn't do something unusual. Sometimes, there's a second sewing ring there. Sometimes, there's a suture tie that's not on top of what used to be the sew ring. So taking a look down into the pocket and extending, sometimes, will save you some trouble when you don't understand why you can't advance your sheaths. AMIN AL-AHMAD: Yeah I find, sometimes, you go in and you don't find the bullet that you used to sew on. And most of the time, it's just in deep somewhere. But sometimes, people take them off and so you have to be-- but you have to do make the effort to look for them and make sure that you can get rid of them. So here what you can see is exposing the inner coil. So you can see there's the inner coil, and what Dr. Canby is going to do now is he's going to advance the locking stylet through that inner coil. Now, this has a radiopaque tip on it so when he does this, we'll be able to follow where that goes. You can kind of see it going down and you can see which lead this would be. So it looks like that's going down the atrial lead. So as we're doing this, I just like to remind the viewers that if you have questions about what we're doing, or any comments, please go ahead and submit those. You can submit them through the platform and we'll have somebody here read them out to us. But we'll continue to narrate the case and talk about what we're doing in the meantime. BOB CANBY: So under the fluoroscopy here, I think you can see the radiopaque tip of the locking stylet now just coming up to the proximal electrode, and then coming in to the electrode itself. So that's where we can't advance any further. So we'll deploy the woven mesh on this locking stylet, which will help it lock it into place. Generally, it locks into any place of curvature. We like to think of it as being about the whole length of the lead, but it's probably in areas where it hits curvatures where it's going to lock the most. I tend to pull on the lead to try to just make sure that it's deployed well throughout. AMIN AL-AHMAD: Now, as we're doing this-- so the next thing we're going to do is tie the insulation so to make sure we have control of the lumen of the lead, but also the insulation of the lead. One of the things I just wanted to mention as we're doing this is if you intend to take only one lead out, what do you do with the other lead, Bob? Do you-- BOB CANBY: Yeah. So many times there's lead to lead binding, and as you pull on one lead the other lead may try to be pulled, as well. So if we're trying to maintain one lead and keep it intact, I'll often take a stiff stylet and advance it down the other lead, just to help give it some additional body. And that sometimes helps in the aid of the lead that you're actually targeting. For tying down the insulation on these leads, what I tend to do is use an 0 Ethibond suture, tie it down tightly to the outer insulation once the locking stylet has been deployed, make sure that's tight. And then I typically tie it to the locking stylet itself. AMIN AL-AHMAD: Yeah, there's different ways of doing this, but I, actually, I like this way. I used to do it the other way, where I tie two sutures to each other and tie it all the way to the back of the locking stylet. But I think this way works just as well. I don't think there's a real, major difference of the two. MALE SPEAKER: Any tips or tricks if you can't get the LLV down? AMIN AL-AHMAD: Yeah if you can't get the locking stylet down-- the question is if we can't get the locking stylet, are there any tips or tricks? That becomes a real challenge. You can still take out leads. You might try a different size locking stylet. In some cases, if you can't get it down you can tie to the insulation, or use other techniques to try to get it down, but those can become more challenging cases. And then in some cases, if you really can't you might have to go from the groin or do something like that. We need the blade. Again, trying to get the insulation and get the lead ready-- prepping this is very important. The more time you spend making sure you get this right is better. You don't want to be in a situation where you're not-- you don't have it just right. That locking stylet here is-- BOB CANBY: And again, my personal philosophy is try to keep all your options open. So sometimes, it's easy to think that it might be easy to take a little bit of a shortcut, not prep something in anticipation you may not need to be doing something with it. But then afterwards, you find out that was a mistake. And sometimes it's very difficult to recover. So try to keep as many options open. We're advancing the locking stylet down the ventricular lead. I don't know where we are yet. Can you see where we are? AMIN AL-AHMAD: Yes, you just got to the tip. So if you pull it back and advance it, you see the free fluoro, so we got to the tip. [INTERPOSING VOICES] So we're going to go ahead and deploy this. There it goes. MALE SPEAKER: Now, do you prep ICD leads different than atrial ones? AMIN AL-AHMAD: Yeah, ICD leads are a little different than their construction. So when we're trying to do a pacemaker lead, it simply has that one lumen, which is the pace-sense lumen. Now, for an ICD lead, of course, there is the pace-sense lumen, which gets prepped exactly the same way, but it also has the cables. What we'll typically do with those is we'll use suture and tie it to the cables, and tie that similar to how we tie the insulation to the back part of the locking stylet. That gives you a lot of help and support. And there's been cases where I've had situations where I could not get a locking stylet down the lumen of the lead, but we were able to control the cables. And just with the cables and the insulation, we're able to get leads out in some cases. [INAUDIBLE] So yeah, that is true. They do act a little differently, from that perspective. It's more to pull on and they're a little bit bigger, so you have to consider that. And then the coil is also important. That's where lead construction matters. So some leads, for example, have silicone backfill of the coil, and that tends to be a nice design for extraction. Versus leads that don't have silicone backfill, there can be a lot of tissue ingrowth into the coil, making your job a little harder in terms of dissection of the fibrous tissue. So we're about ready to start lasering. At this stage, we've already-- I heard you guys already prepped the laser. Just a quick question, Bob. What laser sheath did you choose and why? BOB CANBY: So these leads are 7 French. They've been in the individual for over 10 years. You can guarantee us that we're going to have a fair amount of adhesions to it. I tend to oversize just a little bit. I'm going to use a 14 French. Our sizes are 12, 14, and 16. I'm actually going to use a 14 to start today. I'm going to put an outer sheath over it because I have to retain access on at least one of the leads. And that way, in case there is a lot of fibrosis on the lead that actually keeps the lead from being pulled through the laser sheath itself, I can pull the lead in the laser sheath out and still have access through the outer sheath. And we'll show you how we do that as we move forward. AMIN AL-AHMAD: So a couple of other things. So you could go with a 12, but a 14, I agree, is a better choice. This is the outer sheath. It has a bevel. We're going to go ahead and put the bevel side in so it'll be a dull side out. And you can go either way with that. BOB CANBY: And then the other decision that we always make is, which lead do you go for first? In this individual, I tend to go for the lead that you think is going to be the easiest. These leads are both the same construction. One had the helix come back, the other one didn't. The atrial lead's a little shorter. I think I'm going to go with the atrial lead first and see how that goes. And then move toward the ventricular lead. And sometimes, you have to do both, and we'll talk about that as we move forward with this. AMIN AL-AHMAD: Yeah I think that's a good way to think about it. Because as you take out one of the leads, you really do a fair amount to get rid of the fibrous tissue that's binding the other lead. So oftentimes, taking out the easier lead does help you get the other lead out. So I think that actually makes a lot of sense in terms of how to do something. So we always, at this point, confirm that we have surgical backup. Everybody-- we have our surgical backup is ready, everybody's ready, and we're ready to go. So we've got TE ready in case, we have everything, so we're ready to start lasering at this point. BOB CANBY: So here it's important-- I feel it's important-- to make sure we're really watching what our leads do. If you can tell, I'm trying to stay concentric as possible with my laser sheath, which you can see on the edge of the screen. The other sheath, you can tell, is just coming to the muscle lead interface there. We'll just leave that for now. I'm manipulating this lead just a little bit to see if I can get underneath that other lead. I'm just rotating a little bit. Looks like I'm in a good position. And at this point, I'll put some traction on the lead I'm targeting and apply some laser energy. I'm going to keep the bevel, generally, on the inside of any curve as I go. This has a slight bevel as you can see, so the bevel I want to be on the inside. You can tell where the bevel is on the laser lead by the attachment of the cord to the lead sheath itself. The longest part of the bevel is on this aspect of the sheath. All right. Coming on laser. AMIN AL-AHMAD: So one of the things that you'll see is that it's really a matter of trying to balance your forces. So the force you pull back is similar to the force you push forward. BOB CANBY: Am I on the RV lead? AMIN AL-AHMAD: You may be. Looks like-- the A lead looks like it dropped, though. BOB CANBY: Oh, the A lead dropped. AMIN AL-AHMAD: A lead dropped. You want to match your forces. Meaning, you don't pull harder than you push and you don't push harder than you pull. You try to match them. You can see here that the leads are clearly bound together and so there's definitely some lead-lead interaction. And one of the things we have to decide, at some point, is do we continue on one lead? Or do you switch back and forth? And you get a feel for that as you go. BOB CANBY: And as you can also tell, I tend to use a little bit of a rotational aspect on a sheath just to try to see if I can work through anything that's in the way and getting a feel for what's in advance. Different obstructions feel differently. A snowplowing of the insulation feels different than calcium, feels different than just fibrosis. I've got something in front of me-- I can't really tell right now. I don't see a shadow on fluoro, meaning it's probably not heavily calcified. So we're just going to continue to move forward. AMIN AL-AHMAD: And one of the things you can see is that all of that dissection that Dr. Canby is doing is when he's off of laser. So he's pushing and pulling and rotating and doing all this stuff with the inner and the outer sheaths when he's not lasering. When he lasers, he really has a very steady forward motion as he's pulling back traction, again, trying to balance forces. And again, the key here is for the lead and the laser sheath to be concentric with each other. You don't want to have the lead at an off angle with the laser sheath. You want the laser sheath to be centered around the lead. BOB CANBY: You can see there, my outer sheath is ahead of my laser a little bit. I'm just trying to see-- AMIN AL-AHMAD: A little bit of dissection. And you get the idea, there, the two leads are really, really attached right in that spot. Looks like you may have passed that. A little more dissection with the outer lead here, helping separate the two. BOB CANBY: We may need to go to the other lead-- AMIN AL-AHMAD: To the other lead, yeah. BOB CANBY: You can tell the lead is coming back. In fact, it is going to come back. AMIN AL-AHMAD: Yeah. BOB CANBY: So here, watching that atrial lead, you can see that the electrodes are indeed coming back. I got my laser out as far as I am-- I'm going to have to continue some traction here and this lead may actually retract, but it may not. So it's still caught up on that other lead. I think what I would do, Amin, is-- AMIN AL-AHMAD: Switch to the other lead-- BOB CANBY: --to the other lead and see if that helps me. AMIN AL-AHMAD: Again, you can really see the binding of the two leads together. And it's one of the things that can impact you. And a good strategy, in this case, is to switch between the two. Sometimes, you have to switch tools, go to a mechanical tool. But if you're using laser and things are going well then just switching between the two leads is good. BOB CANBY: You can see here, some of the fibrosis that was around the lead that came out inside the sheath. AMIN AL-AHMAD: Yeah. Is that the-- Go ahead and put that on, please. I can hold this. BOB CANBY: I think, again, a good strategy sometimes, when you have lead to lead binding, switch between the leads, as we've been talking about. That will help, many times, the area that has been bound that you've lased through before is a little easier on the next pass, on the other lead. Here, we're still meeting a little bit of that-- AMIN AL-AHMAD: Early resistance-- BOB CANBY: --early resistance. AMIN AL-AHMAD: Now, if there's calcium-- I'll let Bob do his thing and I'll just talk. If there's calcium, sometimes using a mechanical sheath is helpful. Either using the outer to break up the calcium outer sheath of the laser, or getting the mechanical rotation type sheaths that work really well for that. And I'm putting a little bit of gentle traction on the other lead just to keep it straight. I'm watching for the atrial lead, which I'm holding, just to make sure it doesn't buckle too much or have problems. So when you have two people, one person having some traction on the other lead is sometimes helpful. You can see the ventricular lead has changed position a little bit, which is good. BOB CANBY: Yes. It feels like snowplowing here a little bit, is what I'm perceiving, I'm feeling here. You see my outer sheath has advanced in front of it a little bit. And I'm just trying to rotate the lead and see whether I can get a free-- it doesn't feel like it's freely moving over the lead at this point, which makes me wonder whether I need to upsize actually. AMIN AL-AHMAD: Yeah. So that's one strategy, is upsizing to the next size, which would be a 16. You can see how the bevel is really pointed away, which is kind of what Dr. Canby was talking about earlier. So that's good. It looks like you may have just-- BOB CANBY: [INAUDIBLE] AMIN AL-AHMAD: Yeah, break it up with the outer a little bit there. BOB CANBY: Slow, steady pressure there. Trying to balance the pushing I'm doing with the laser with how I'm pulling on the lead, as well. AMIN AL-AHMAD: And see, the other thing is as he pushes the laser forward, he's pushing the outer forward. Because remember, again, if this lead comes back, he's going to want to retain access. And so that helps you so you can just pull out the laser keeping with the outer. We, typically, will have a wire ready to go so you don't have to hold too long. BOB CANBY: Definitely fibrotic. AMIN AL-AHMAD: Yeah, it's stucked in. Looks like the outer's making progress. Something there loosened up. See how the tips are really were connected right there. It's that last spot-- this is kind of towards the SVC so we're very mindful here to be-- BOB CANBY: You can see from Dr. Al-Ahmad, the other lead is-- AMIN AL-AHMAD: No, no, I don't want to break it. OK. BOB CANBY: We may come back to that and get it-- AMIN AL-AHMAD: Overexcited with that one. BOB CANBY: Just re-getting my bearings on this other lead. Again, I'm trying to keep the bevel when I'm active on the laser to the inside curve, as you can see. I still feel that I've got part of the lead snowplowing in front of me, is what it feels like. That's why I'm rotating to see if I can just get over it. AMIN AL-AHMAD: It's amazing how these leads get adhered to each other and really-- there, that made progress. That's one of these things-- again, when you're trying to take out a single lead, be prepared that you might have to take out both. Always be prepared. And prepare the patient for that. Tell the patient in advance that although our plan is to pull out a single lead-- you can see the V lead there is going. BOB CANBY: What I want to do here is make sure I don't lose the access so I'm just going to look to see if this lead will come back at this point. Still not completely freed up there. AMIN AL-AHMAD: That's a stubborn lead. BOB CANBY: That is a stubborn lead. AMIN AL-AHMAD: You want me to grab that? BOB CANBY: I'm just trying to-- AMIN AL-AHMAD: Use the outer-- BOB CANBY: Use the outer to clear that a little bit. Boy, that thing does not want to come, does it? AMIN AL-AHMAD: No. BOB CANBY: I want to just see if it'll all come back in. No. That thing does not want to come out there. AMIN AL-AHMAD: I wonder if that's just the big-- that's where things finally ended up. BOB CANBY: I may have to lose access-- AMIN AL-AHMAD: Lose access-- BOB CANBY: --and just pull it out this way. AMIN AL-AHMAD: We could double wire the other one. Which is the other thing about options, which was what Bob was telling you earlier. You have options because we've-- OK. Yeah, that's why. That's a lot of fibrous tissue that ended up getting kind of snowplowed there, towards the end. You see that? How's our blood pressure? And can you look at the TE real quick, please? [INTERPOSING VOICES] OK. Blood pressure is stable so we're doing OK. Let's take a quick look at the TE. I don't know if-- can the camera see this, Matt? What's that? Oh, camera's right here. Yeah. You can see here how the tip was kind of free, but a lot of this stuff may have been pushed forward and made this bundle like this, making it harder to take it out. And can kind of see here, as you try to pull it out, it just doesn't want to come. So pulling the whole thing out made a lot of sense in this case. Blood pressure is stable. And you can see with these large [INAUDIBLE],, as you pull them out, you sometimes will get bleeding in the pocket and so holding some pressures is critical here. BOB CANBY: Anesthesia made a very important comment for us, too, here. She said they haven't had to give any pressers or anything to help support blood pressure. I think one of the important communications in these cases is with your anesthesia support and physicians is to have good communication. So that, if for some reason, they noticed the blood pressure is low, and want to support it, they let you know that that's what's going on. The time where that's critically important is if something is going on and the blood pressure's falling, and you're worried about bleeding or some other complication from your procedure. But then the patient gets a presser and the blood pressure looks good, you may think you're out of the woods. But you're actually just potentially delaying the inevitable, so having that communication, know what's going on, is important. All right, so the ventricular lead is out in its entirety. We're going to see what we can do with the remainder of the atrial lead. AMIN AL-AHMAD: One of the things that we've talked about a couple of times, and I've regretted not doing at times, is-- BOB CANBY: It came out. AMIN AL-AHMAD: That's the atrial lead. OK. So it was really backed up. You can see the whole atrial lead just came right out in the end. So here it is. BOB CANBY: Checking on fluoro, so yes. AMIN AL-AHMAD: It looks good. So right now, we usually will just take a quick sweep of the-- drop the [INAUDIBLE] please-- quick sweep of the lung field, make sure that there's nothing there. But when you have a superior vena cava bleed, these really bleed fast and it's not subtle-- BOB CANBY: All the way over-- AMIN AL-AHMAD: All the way over-- BOB CANBY: [INAUDIBLE] the way. We're looking at the angles of the pleural space and just to make sure everything remains looking sharp, which they do on both sides. So that seems to be promising. The blood pressure is quite stable. The TE shows that there was no evidence of a pericardial effusion. So I think we're in a good position with the leads removed. AMIN AL-AHMAD: So then, again, the option here is easy implant because we already have access so we don't have to worry. And we can double wire that, that's not an issue. The one thing I was mentioning is sometimes, I've found that-- BOB CANBY: Oh. Let me change gloves and stuff. AMIN AL-AHMAD: OK. Sometimes, I found that-- BOB CANBY: I'm going to need a new set of gloves, please. AMIN AL-AHMAD: --putting a suture around where the leads are helps prevent some of the back bleeding. Because sometimes, especially with a 16 French, as you remove the leads, you get a lot of back bleeding. That's particularly true in people with heart failure and high venous pressures, as well. BOB CANBY: While we're waiting, let me just change subjects a little bit. I don't know whether when I initially was getting access to the pacemaker pocket here, this patient had a very large keloid. And so what I did was I cut around the keloid, that's why my incision looks wide, but it's not going to be hard to bring it back together again. So I tend to remove the previous scar by cutting around it and then extending down into the pocket. On this particular patient, when we got into the pocket it was actually quite calcified. And in fact-- Carlos, do you have the-- you have it there, OK. So the capsule itself was very calcified. When they're calcified-- and I don't know if you can appreciate this-- you can almost hear an eggshell component as I'm moving the outer capsule and fibrotic tissue. When it's thick and very calcified, that's when I will tend to manage the pocket by removing the capsule. There's a trade off in taking out capsules. There's going to be a little high risk of hematomas. At the same time, you're going to be able to implant the device into more vital tissue so potentially, one could argue that there might be a little lower infection risk. At the same time, it's a judgment on patient to patient, but I don't know about you, Amin. I don't like a lot of calcium. AMIN AL-AHMAD: I agree. I agree. Another thing to bring up is, which you'll see-- I'm actually going to step away a little bit. I'll still talk and take some questions. I'm going to give Bob a little bit more room here-- is that he's now going to use some long sheaths for reimplant. And as he's doing that, we're kind of watching the time and watching how stable the patient is. And at some point, we're just going to-- we'll call the OR off. We'll let them know that they're good to go. We don't keep the OR here for the whole reimplant. We'll just keep them here until we believe that everything is safe and stable. And that should be soon because this was not a terribly difficult lead extraction. There wasn't anything that happened during the extraction that was too scary, so we'll call off the OR pretty soon. BOB CANBY: Yeah, I think usually it's about five to 10 minutes is what we do. AMIN AL-AHMAD: Yeah, about five to 10 minutes. BOB CANBY: I'll let Dr. Neely and my colleagues over there know everything went fine and we're in good position. AMIN AL-AHMAD: So good communication between the teams. But what Dr. Canby is going to use now is a long sheath. And I've been in situations where I have not used the long sheath and I've regretted it. Because although you think that you've gotten beyond some fibrous tissue, occasionally, you just have problems where you just can't get the lead to go down. So a long sheath helps a lot, especially if the venogram wasn't great and you couldn't tell exactly where all the fibers binding of the leads ended up. So we'll often use that. And it's not so hard to implant with a long sheath. MALE SPEAKER: Can you explain your relationship with your CT team? AMIN AL-AHMAD: So the question we got was, can you explain your relationship with the CT surgery team? So hopefully, we have a good relationship with them. They work really well with us and we work well with them. Typically, we'll have these cases booked on our schedule and on their schedule, in advance, so that we have somebody who's here. If the case is going to be worrisome, if it's-- a lady, not long ago, that had leads over 20 years-- might ask the CT surgeon to hang out in the room. We might have things more ready. If it's a fairly routine straightforward case, then we just have to confirm that the CT surgeon is in the hospital nearby, ready to go, in case we have a problem. Having seen problems firsthand, I can tell you they happen quickly, so having a good relationship is critical. We like doing these cases first thing. It's easier that way for us and for them because we're not worrying about them finishing their case and us putting this one on the table. And when do you put this on a table? How do you time it? All that sort of stuff. MALE SPEAKER: Do you use the bridge balloon all the time, or just high risk patients? AMIN AL-AHMAD: So the question is, do you use the bridge balloon all the time? Or do you use it for high risk patients, and how do you define high risk? Yeah, that's a good question, honestly. The bridge balloon really is a great idea in that it can save you time. Again, having seen a bleed firsthand-- and fortunately, the patient lived through it-- I can tell you there's so much blood it's unbelievable. So having the ability to at least blow up that balloon, delay things, allow the surgeon to see where the problem is, is really critical. So if leads are really, really old or the patient factors suggest problems, then we'll put up the bridge balloon, the actual bridge balloon, and go from there. On the other hand, if they're considered low risk, then what we'll typically do is just put up the wire and be ready to put up the balloon if we have to. So those are the two scenarios. So a low risk patient might be-- thank you, appreciate it. The surgeons are off. We're good. If less than 10-year-old lead, something like that, less than eight-year-old lead-- again, it depends a little bit on what you perceive your risk would be based on your experience, and so forth. But we would, generally, if we feel it's a high risk procedure, multiple leads, ICD leads, patient issues, then we'll put up the bridge balloon early, size it, figure out where it's supposed to go, and then go from there. MALE SPEAKER: Any tips and tricks to taking out a fine line or other challenging leads? AMIN AL-AHMAD: So the question is, any tips or tricks taking out a fine line or any other challenging leads? Lead design matters, and the different models matter. So you want to make sure that you understand what lead you're taking out. The fine lines have a fixed helix so you're not going to be able to retract it. Trying to turn the lead around, generally, doesn't work to unscrew it. That's one of the problems with fine line. The insulation on fine line tends to be a little bit friable, too. What we typically will do with the fine line is, actually, not cut the lead. So we'll cut off the little silicone fins that fit into the header and then and then lock it with the lead still intact, not cut. And then the laser over that with the 14 French. And that, typically, works reasonably well With them. And then the other leads that are particularly-- things to think about are Riata leads-- those, you almost always tend to have to go to a 16 French laser sheath with those. So that's one thing to consider early on, is just go to a bigger French extraction system if you have to for those. MALE SPEAKER: We've got a comment from Dr. Schaller. Congratulations on a great case. What do you think about using a [INAUDIBLE] AMIN AL-AHMAD: Thanks, Rob. If Rob Schaller does it, then it's probably the right thing to do. So we do use it, actually, for some cases, absolutely. I could go either way. I mean, we tend to do a lot of that dissection with the outer, in certain locations. And having a VisiSheath is actually really nice for that. So I can't disagree with Rob. He does these and he's very good at it. MALE SPEAKER: That's about it for right now. I think that questions are still coming in. AMIN AL-AHMAD: OK, very good. Yeah. So I think at this stage, we're reimplanting the leads. Atrial and ventricular lead are about to go in. Looks like Bob may have double wired the access port, so that we're able to, now, put in two sheaths and two leads for this. And again, the whole time we're watching patients-- it's rare to get bleeds that occur slowly, but they can happen. You can get a late tamponade or late problems. That does occur in some cases. So obviously we watch these patients. Many of these patients will stay overnight in the hospital. If it's a really easy extraction, upgrade, whatever, some of them may actually go home. But again, if something difficult, we'll watch overnight and be careful. If it's a lead extraction and they start becoming hypotensive later on, it's tamponade until proven otherwise. So you have to be cautious about that. And you'll know based on the procedure how much time you spent pulling and pushing in certain areas, and so forth. How are we doing? Any other questions we should-- MALE SPEAKER: Let's come in-- AMIN AL-AHMAD: OK. Oh yeah, so I'm reminded to remind you all-- whoever's watching, we appreciate your watching-- to ask any questions that you have. We have about another eight minutes and we will be happy to take any questions with it. One question I get frequently in people when they're starting a program, is which leads to tackle and how to go about that. And one way to do this is really start with the class I indications. And you know don't be shy about referring cases that you're not comfortable with. I've been doing extraction for 17 years and when I see a tough, tough case I'll typically do it with another operator so we have two people. We can bounce ideas off each other if there's problems, things like that. And it's helpful to have a second person in those circumstances. So as you start, start with clear indications, start with leads that you know are going to be straightforward leads, build up your experience that way. And then, as you become more and more experienced, I think you can start to tackle more difficult cases. And again, don't be shy about referring things that you feel are still a little bit out of your experience level. And again, I've been doing this for a long time and I still tag team and double team with others when I have to. MALE SPEAKER: Still waiting on a few. AMIN AL-AHMAD: One other thing to bring up-- in some cases, we'll use-- obviously, if it's a infected pocket, we will break down the whole scrub. And if we're able to implant in the same setting, we'll do that on the opposite side, obviously, but a whole new setup. We don't use the same setup for those. Many times, when they're infected, you can't do that and you have to put in a temporary pacing catheter. So we can usually do that through a standard pacemaker lead through the jugular vein, or through the subclavian vein, or something like that. Just put that in, screw it in, and then and then attach that to an old device. That works reasonably well for those. MALE SPEAKER: Now, if you do need to snare, what's your approach? Specific tools, or when you need to retain access-- AMIN AL-AHMAD: Yeah. MALE SPEAKER: [INAUDIBLE] AMIN AL-AHMAD: Yeah, there's a lot of different ways to snare these-- move this way? OK-- a lot of different ways to snare these, so it depends a little bit on what you're left with. So if you have a lead where you can't get the edge of the lead, then you may need sort of a needle eye snare. Those are cumbersome, not always easy to use. Another technique, which I learned from other people, is you could put up a catheter, get around it, and then gooseneck the catheter. And then, use that as a platform to snare. If you do have a lead where the tip is free, then gooseneck works really, really well. Typically, I don't mess around with a 10. I go with a 20 gooseneck so it's big, and you can usually get in. It's nice to have a lead with a large sheath with a little bit of a cant on it. So not a straight sheath if you're going to use a gooseneck because you do want to direct it. Sometimes, you might even need something like an Agilis, to direct it, to get the gooseneck to go where you need it to go. It seems like it should be easy to just put it up there and gooseneck something, but sometimes, you do have to direct these to find the right spot to get it. So that that's one way to do it. MALE SPEAKER: Fantastic. And we had a question come in about the benefits of mechanical tools adjunct to a laser. AMIN AL-AHMAD: Yeah, there are benefits. I mean, sometimes, there's just calcium you can't get through. There's fibrosis you can't get through. And so the mechanical tools work really, really well. And we've learned from some of the experience from these other folks in other countries where laser is not available, mechanical tools are available. And they've done a really good job being successful just with mechanical tools alone. So they do work. For me, I find that it'll-- if you keep doing that, it'll hurt your arm after a while. So you got to alternate leads, alternate arms, take a break here and there. But they work. I think for some people, it's very useful for the first part. So you can use the mechanical tool, get through the first area of fibrosis, and then switch to a laser tool. That works really well. And again, the areas of caution are the superior vena cava area where you want to pull a little bit, make sure that you're off of the wall vena cava if you can. So the leads are being implanted. I think we have about a minute left so I just wanted to take the-- you got any questions come in, or--? MALE SPEAKER: There's one more question. Dr. Canby said that the type of resistance, snowplow, calcium, et cetera, feels different. Can you explain that, how that feels? AMIN AL-AHMAD: That's a hard one to explain. If you push and you just feel like you're hitting a wall, oftentimes, that's-- especially if you're starting to pull-- you saw at the end-- so at the end of this case, you saw as we were pulling back, the lead just wouldn't come into the sheath. That's kind of what you feel with snowplowing. You're pulling and you just can't get over the thing. That's very different than calcium. Calcium just feels a little different. It's kind of hard-- it's a little more crunchy, I guess. You can see it sometimes. And then oftentimes, the outer helps you get through-- the outer will help you get through both of those circumstances. But even when the outer goes, you still can't get the inner if it's snowplowing. And so that's one way to tell the difference. MALE SPEAKER: And when do you decide to upsize? AMIN AL-AHMAD: If you're not making progress, I think it's time to think about upsizing or a different strategy. Go to a different wire or something like that. We're good? OK. I just wanted to thank everybody here and thank all of our staff here. Thank Dr. Canby, my colleagues, everybody, and appreciate everybody watching. Thank you so much. Thanks to Philips, also. Thanks. [MUSIC PLAYING]