A steerable introducer‐assisted wire‐loop snare technique: A bailout for unsuccessful lead extraction by a Needle's Eye Snare

The Needle's Eye Snare (Cook Medical) is an effective tool for extracting leads via a femoral vein. However, it sometimes fails to grasp the lead. We describe an alternative method of successfully grasping a lead by creating a wire‐loop around the lead with the help of a steerable introducer.

The Needle's Eye Snare (Cook Medical) is an effective tool for extracting leads via the femoral vein. Its advantage is the ability to grasp a lead without a free end, which enables a combined superior and femoral approach. 1 However, it sometimes fails to grasp the lead. We describe an alternative method of successfully grasping a lead by creating a wire loop around the lead with the help of a steerable introducer.
A 63-year-old man with a complete atrioventricular block was referred to our hospital for lead extraction and upgrade to a device for cardiac resynchronization therapy. Thirteen years earlier, he had undergone an implantation of a ventricular pacing lead (Brilliant S+ VDD, IMW 15Q 58 cm; Vitatron). Transvenous lead extraction was attempted in a hybrid operating room by dedicated cardiologists and cardiac surgeons while the patient was under general anesthesia.
First, a superior approach via the implant vein was attempted; however, it was unsuccessful owing to the difficulty in coaxially aligning the powered sheath with the targeted leads. The insertion of the Needle's Eye Snare through the femoral vein was subsequently attempted, but this was also unsuccessful in catching the lead because the snare was not a steerable device. Consequently, the snare could not be coaxially aligned with the lead (Video S1). Then, we used an alternative strategy; an Agilis NxT steerable introducer (Abbott) was We used an Agilis NxT steerable introducer-assisted wire-loop snare technique to extract a lead when a Needle's Eye Snare was unsuccessful in grasping the lead. One of the strengths of this method is the ability to encircle the lead inside the RA. Moreover, snaring the guidewire would be easier in the IVC than in the RA because an EN Snare system in the IVC would be more easily aligned coaxially with the guidewire for snaring. An alternative approach would be to catch the tip of the ablation catheter with a snare after the ablation catheter encircles the lead in the RA. Notably, this approach is similar to the technique described here, except that the location where the guidewire/ablation catheter is caught with the snare is the IVC in our approach and the RA in the alternative approach. Therefore, our approach was considered easier for snaring.
A combined superior and femoral approach has several advantages. 1 First, it creates a strong rail to facilitate powered sheath advancement. Second, it lowers the risk of superior vena cava (SVC) laceration compared to a superior approach alone by creating a greater separation between the lead and the SVC wall. Third, this This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited. approach helps to gain cardiac chamber access by guiding a powered sheath through a venous occlusion in cases of occluded superior veins. Conversely, the disadvantage is the risk of a femoral hematoma. We believe that to extract a lead through a combined superior and femoral approach, it is critical not to unnecessarily persist with the Needle's Eye Snare since an excessive number of attempts could cause atrial injury. 2 The Needle's Eye Snare is not useful in catching the lead when the snare is not coaxially aligned with the targeted lead or when no interstice is between a lead and SVC wall. In the latter situation, the "spaghetti twisting" technique would become difficult in catching a lead. 3 Therefore, in these situations, an alternative to the use of the Needle's Eye Snare is necessary, as described in the present case. Additionally, the Japanese Lead Extraction registry 4 revealed that snare techniques, which are usually used via a femoral approach, accounted for 15.2% of all lead extraction methods.
Subsequently, lead extractors occasionally encounter situations where snares are required. Therefore, they should become familiar with the technique described here as a bailout for unsuccessful lead extraction using a Needle's Eye Snare.

FU N D I N G I N FO R M ATI O N
No funding was received for this study.

CO N FLI C T S O F I NTE R E S T
The authors declare no conflict of interest for this article.

A PPROVA L O F TH E R E S E A RCH PROTO CO L
The clinical description of this report was approved by the Institutional Review Board of Sendai Kousei Hospital (approval no: 4-8; approval date: May 16, 2022).

I N FO R M ED CO N S ENT
Written informed consent was obtained from the patient to publish this report.