Wire ThRoUgh Snare Twice (Wire TRUST) technique: A novel method to grasp a lead with inaccessible ends as a supportive femoral approach for transvenous lead extraction

Transvenous lead extraction (TLE) is a crucial procedure for managing cardiac implantable electronic devices. The use of a combined superior and femoral approach has been found to enhance the success rate of TLE. This report introduces a novel technique, named “Wire ThRoUgh Snare Twice” (Wire TRUST), for effectively grasping a lead without a free end during TLE.

Transvenous lead extraction (TLE) is essential in the long-term management of cardiac implantable electronic devices.TLE is necessary in cases of lead infection, lead damage, lead extraction for transplant, or lead replacement. 1Superior lead extraction is frequently used as the primary approach for TLE. 2 In some cases, using both the superior and femoral approaches for lead extraction may be necessary to achieve successful lead removal. 3The femoral approach can be useful in a situation where there is limited space between the lead and the superior vena cava.In this situation, creating sufficient separation to allow for the safe and effective removal of the lead using only the superior approach is difficult.The femoral approach may be necessary to facilitate the advancement of a powered sheath via the superior approach.Grasping a lead without a free end is difficult.The needle's eye snare (NES) (Cook Medical Inc.) is an effective tool to grasp a lead without a free end. 3 However, the size of its loop cannot be changed and the threader is rigid.Therefore, there are instances where the loop fails to grasp a lead, leading to unsuccessful procedures and complications, such as cardiac tamponade and atrial septal perforation. 4In this report, we propose a new method of successfully grasping a lead without a free end named the "Wire ThRoUgh Snare Twice" (Wire TRUST) technique.

| CASE REPORT
A 49-year-old male patient had undergone a dual-chamber pacemaker (Accent MRI; Abbott) implantation for intermittent complete atrioventricular block 9 years previously.He provided written informed consent for the handling of his data.He was referred to our hospital for TLE and replacement of the right ventricular (RV) lead (Tendril MRI LPA1200M/52 cm; Abbott) after multiple presyncope episodes owing to electrical artifact on the RV lead.There were no remarkable findings on a chest X-ray.A pacemaker check at our hospital showed multiple episodes of electrical artifacts in the RV lead, but no issues with the right atrial (RA) lead (Tendril MRI LPA1200M/46 cm; Abbott).The patient was scheduled for TLE, replacement of the RV lead, and pacemaker generator exchange.
We performed TLE with cardiac surgery backup in a hybrid operating room under general anesthesia using a combined superior and femoral approach called "Tandem" to achieve co-axial alignment of the powered sheath with the RV lead.Initially, we freed the device from its left prepectoral pocket and dissected the RV lead free in the superior approach.We then inserted a locking stylet (Liberator Beacon Tip; Cook Medical Inc.), which could reach the lead tip, but the fixation helix of the RV lead could not be unscrewed.A locking stylet was then deployed and secured on the lead using a one-tie accessory (Cook Medical Inc.).
After confirming the patency of the subclavian vein, we performed subclavian vein puncture more distally before the lead extraction procedure to establish a new access route for the new RV lead.
Simultaneously, we initiated the femoral approach using the Wire TRUST technique.The process of the Wire TRUST technique was as follows.First, a 14-Fr sheath (Check-Flo Performer; Cook Medical Inc.) was inserted into the right common femoral vein (CFV).A 4-Fr pigtail catheter (Terumo) was inserted into the 14-Fr sheath and advanced in the RA by hooking the ventricular lead under multidirectional fluoroscopic guidance (Figures 1A and 2A).A 0.014-in.guidewire (Hi-Troque Command 300 cm; Abbott Vascular) was then inserted and advanced through the pigtail catheter.After crossing the ventricular lead, the 0.014-in.guidewire was further advanced to the inferior vena cava (IVC).A 6-Fr snare catheter with a 35-mm-diameter loop (ONE Snare; Merit Medical) was inserted into the 14-Fr sheath side by side with the pigtail catheter and then advanced into the IVC and opened in advance (Figure 2B).The distal side of the 0.014-in.guidewire was passed through the ONE Snare and withdrawn into the 14-Fr femoral sheath for wire externalization (Figures 1B and 2C,D).After the removal of the pigtail catheter (Figure 2E), we passed both ends of the 0.014-in.guidewire through the snare outside of the body (Figures 1B   and 2F).The snare was then closed and reinserted into the 14-Fr sheath (Figure 1B).After the snare catheter emerged from the tip of the sheath, the snare in the expanded position was advanced up to the vicinity of the lead (Figure 2G).Simultaneously advancing and closing the snare while tensioning the 0.014-in.guidewire after externalization securely held the lead (Figures 1C and 2H).
The RV lead was then extracted using a 14-Fr GlideLight laser sheath (Philips) after firmly grasping it with the Wire TRUST technique (Figure 1D,E).A new RV lead (Tendril STS/2088TC-58cm; Abbott) was inserted using a newly established subclavian vein puncture site.This lead was not removed because there were no issues with the data for the RA lead compared with before the procedure.The extracted lead showed fibrotic tissue with calcification.A new generator (Assurity DR MRI; Abbott) was implanted, and the procedure was completed without any complications.

| 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. 3,5Furthermore, 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, F I G U R E 1 (A) A 4-Fr pigtail catheter hooked the ventricular lead under multidirectional fluoroscopic guidance.(B) After 0.014-in.guidewire externalization, both ends of the guidewire were passed through the snare, and the snare was reinserted into the 14-Fr sheath.(C) Simultaneously advancing and closing the snare while tensioning the guidewire enabled grabbing the lead without a free end.(D) A 14-Fr GlideLight laser sheath was advanced while grasping the lead by the Wire TRUST technique.(E) The right ventricular lead was successfully extracted using the 14-Fr GlideLight laser sheath.which has been reported to be safe and effective. 6,7When 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.
In the Wire TRUST technique, there are two procedures to pass the 0.014-in.guidewire through the ONE Snare: (1) the first procedure involves passing the 0.014-in.guidewire that has crossed the V lead through the snare in the IVC and (2) the second procedure involves passing both ends of the wire through the snare outside the body after externalizing the 0.014-in.guidewire.In the first procedure, 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-in.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-in.guidewire into the pigtail catheter causes the pigtail portion to stretch and may release the hook on the V lead.Therefore, a 0.014-in.guidewire is essential for this technique.
It is important to hook the lead in the RA, which is closer to the IVC, rather than the RV.This is because snaring in the RV could cause damage to the tricuspid valve apparatus.However, if it is still challenging (e.g., an enlarged heart), the use of a steerable introducer can be helpful.To facilitate the easy approach of the distal end of the 0.014-in.guidewire into the IVC, proper shaping should be applied to the 0.014-in.guidewire.If the wire does not advance into the IVC, one can bring the snare up to the RA.This way, the distal side of the 0.014-in.guidewire can be passed through the ONE Snare in the RA.Furthermore, to identify the inadvertent capture of both the targeted lead and nontargeted lead, multidirectional fluoroscopic guidance can provide valuable information.If there is any doubt, gently pulling the pigtail catheter can help determine whether both leads have been inadvertently captured.If both leads are indeed captured, a slight advancement and rotation of the pigtail catheter can release the | 1993 hook, allowing for their separation.After releasing the hook, one can try using the pigtail catheter again to specifically hook the targeted lead.
A previous report showed the usefulness of a pigtail catheter for retrieving catheter fragments with inaccessible free ends. 8The safety of the Wire TRUST technique depends on which type of 0.014-in.guidewire is used.Regarding the type of 0.014-in.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.Moreover, a 300-cm wire is recommended because it needs to be folded and grasped with a snare for later externalization, requiring a length of about three times the distance from the right CFV to the RA.
Although the use of a 0.014-in.guidewire raises several concerns, they can be mitigated during the procedure.First, if the wire breaks, it can be promptly retrieved since it is external to the patient's body.
Moreover, fluoroscopy can be used to periodically check whether the portion of the lead held by the Wire TRUST technique is experiencing any breakage or deformation.Last, if the guidewire becomes embedded in the insulation of the lead, one can push and pull the lead and the 0.014-in.guidewire to release the embedding.If this proves to be challenging, the lead can be retrieved through a femoral sheath while maintaining the grip using the Wire TRUST technique.
Simultaneously inserting a 4-Fr pigtail catheter and a 6-Fr snare catheter is necessary.Therefore, a large-diameter sheath of ≥10 Fr would theoretically be required for this technique (a 14-Fr sheath was used in this case).
When the lead becomes free at the distal end during the procedure, unlike the loop snare with a deflectable electrophysiology catheter, 9 the Wire TRUST technique allows us to tightly grasp the snare on the lead, in a way that is similar to the NES.This advantage becomes critical when, for example, crimping the lead and the locking stylet together is helpful. 10Moreover, because of externalization of the 0.014-in.guidewire, manipulating the guidewire by pushing and pulling to adjust the position where the lead is held by the snare is easy (see Supporting Information: Video).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.

F I G U R E 2
Schematic drawing of the "Wire TRUST" technique.(A) A 4-Fr pigtail catheter hooks the targeted lead.(B) A 0.014-in.guidewire is inserted into the pigtail catheter, crosses over the lead, and then passes through the snare.(C) The 0.014-in.guidewire retracts into the 14-Fr femoral sheath.(D) Externalization of the 0.014-in.guidewire (bottom half).(E) Externalization of the 0.014-in.guidewire (top half).(F) Removal of the pigtail catheter.(G) Both ends of the guidewire are passed through the snare outside of the body and inserted into the 14-Fr sheath.(H) Advancing and closing the snare while pulling the 0.014-in.guidewire can hold the lead.