Multidisciplinary Lead Extraction and Baffle Obstruction Relief
Manual traction of the non-functioning LA lead demonstrated complete attachment to the subclavian vein and SVC. To increase the safety of the extraction procedure and to provide hemostasis in case of an SVC tear, an occlusive balloon (Bridge Occlusion Balloon 590-001, Philips) was deployed in the SVC by way of the right internal jugular vein. Attempt retracting the active fixation mechanism of the lead was unsuccessful. A locking stylet and short-length mechanical dilating rotator sheath (9F TightRail™ Sub-C 560-009, Philips) was used to lyse the adhesions from the entrance of the lead into the subclavian vein. The dilator was exchanged for a long rotational sheath (9F TightRail™ 545-509, Philips) (Figure 2 ) and the adhesions for the rest of the lead from the turn of the SVC into the baffle were released. The tip of the lead was firmly embedded inside the atrial baffle and could not be safely extracted despite multiple attempts (Figure 3A ). The use of the mechanical dilating rotator sheath almost completely relieved the stenosis at the baffle ostium as a side effect (Figure 3B ). Due to resolution of stenosis, lack of progress, and an increasing risk of perforation, a decision was made not to proceed with complete extraction of the lead. The lead was cut and capped near the entry into the subclavian vein and the procedural site was closed. The patient was then fully anticoagulated.
A 10 x 27 mm Visipro balloon expandable stent was advanced into the RIJ vein, positioned safely across the stenotic segment of the baffle, and deployed with a 14-mm balloon (Figure 3C ). Repeat angiography demonstrated very brisk flow from the SVC through the baffle with no residual pressure gradient (Figure 3D ). Anticoagulation was reversed and the stent delivery system was removed.
At her one month follow up, the patient remained on dofetilide and Eliquis for rate control and anticoagulation, respectively, with no symptoms nor complications.