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Simultaneous lead extraction and vacuum-assisted vegetation removal

The incidence of infection associated with cardiac implantable electronic devices (CIEDs) is rising at a rate faster than that of the number of implants. CIED infections typically require complete device and lead removal. The prevalence of vegetations is high in patients with infective indications who are referred for lead extraction. Because of the risk of hemodynamically significant pulmonary embolism associated with percutaneous lead extraction techniques, management of those with large lead vegetations continues to be challenging. Often, patients with vegetations larger than 20 mm in diameter are referred for consideration of open surgical lead extraction and debridement. We report a case of a patient with large lead vegetations in whom percutaneous lead extraction was performed with concomitant percutaneous removal of the vegetations using the AngioVac aspiration system (AngioDynamics Inc, Latham, NY).


Introduction
The incidence of infection associated with cardiac implantable electronic devices (CIEDs) is rising at a rate faster than that of the number of implants. 1 CIED infections typically require complete device and lead removal. The prevalence of vegetations is high in patients with infective indications who are referred for lead extraction. 2 Because of the risk of hemodynamically significant pulmonary embolism associated with percutaneous lead extraction techniques, management of those with large lead vegetations continues to be challenging. Often, patients with vegetations larger than 20 mm in diameter are referred for consideration of open surgical lead extraction and debridement. [2][3][4][5][6] We report a case of a patient with large lead vegetations in whom percutaneous lead extraction was performed with concomitant percutaneous removal of the vegetations using the AngioVac aspiration system (AngioDynamics Inc, Latham, NY).  Figure 1). Open surgical lead extraction was expected to be associated with prohibitively high operative risk. Therefore, percutaneous lead extraction was planned with concurrent debulking and aspiration of the vegetations using the AngioVac aspiration system.

Case report
The procedure was performed in a hybrid cardiac catheterization laboratory under general anesthesia. A 26F sheath (Check-Flo Sheath; W.L. Gore & Associates, Flagstaff, AZ) was placed in the right femoral vein, and a 16F reinfusion cannula was inserted percutaneously in the right internal jugular vein for the return venous cannula. The AngioVac cannula (Vortex Medical, Norwell, MA) was advanced via the femoral vein into the right atrium over a stiff guide wire, and a standard balloon inflation device was used to open the balloon-actuated funnel tip. Intravenous unfractionated heparin was administered to maintain activated coagulation time at 300-400 seconds. Using the EN Snare endovascular snare system (Merit Medical, South Jordan, UT), a large vegetation was removed under transesophageal echocardiography guidance ( Figure 2; Movie 1, available online) and then pulled back to the AngioVac device, where it was successfully suctioned off and removed and trapped in the filter ( Figure 3).
Then, the ICD right ventricular lead was unscrewed from the myocardium and a long locking stylet was passed into this lead. A laser-powered sheath (SLS II Excimer Laser Sheath; Spectranetics, Colorado Springs, CO) was advanced over the lead under fluoroscopy guidance. As the laser sheath neared the superior vena cava, the lead tip was freed with countertraction. Subsequently, a 20 mm gooseneck snare was advanced (from the femoral vein) around the freed end of the ventricular lead and as far as it could reach up the body of the lead. The snare was then tightened on the lead and moved toward the lead tip to "strip" the lead from attached vegetations ( Figure 2B; Movie 2, available online). Lead extraction was performed while AngioVac suction was active. The same procedure was repeated for the atrial and left ventricular leads.
The patient's symptoms resolved within 24 hours. She had no clinical evidence of pulmonary embolism, and she was discharged from the hospital within a few days with a wearable external defibrillator. A new biventricular ICD system was implanted on the opposite side after completion of antibiotic therapy and confirmation of complete resolution of infection. Colonoscopy revealed precancerous colonic polyps.

Discussion
The rate of CIED utilization has been rising over the past decade, and the incidence of CIED-related infections has been increasing at an even faster rate. 1 Complete device and lead removal is recommended (class IA) in patients with definite CIED infection. Those patients usually have a high prevalence of lead vegetations. While percutaneous lead extraction techniques are generally safe and feasible in patients with small vegetations, 6 the risk of massive, hemodynamically significant pulmonary embolism in those with large vegetations is usually prohibitive for the percutaneous techniques and requires referral for open surgical lead extraction and debridement. [2][3][4] The AngioVac aspiration system is a catheter-based technique that allows suction, filtering, and reinfusion of blood, and has been used for removal of unwanted intravascular material, such as central venous thrombi and

KEY TEACHING POINTS
Lead vegetations are common in patients with infected cardiac devices.
Large lead vegetations can prohibit percutaneous lead extraction owing to high risk of severe pulmonary embolism.
Use of the AngioVac aspiration system performed simultaneously with percutaneous lead extraction can present an acceptable alternative to open surgical lead extraction in these patients.
vegetations. The AngioVac circuit consists of a centrifugal pump and console, standard extracorporeal bypass tubing, and a filter. The inflow component of the circuit is connected to the proximal end of the AngioVac cannula, while the outflow component is connected to a reinfusion venous cannula. The AngioVac cannula has a balloon-actuated, funnel-shaped distal tip. Adjustable suction is applied to the tip of the AngioVac cannula, to facilitate venous drainage and removal of unwanted intravascular material. The blood is filtered during extracorporeal bypass (thereby removing unwanted intravascular material) and is then returned to the venous system via the reinfusion cannula.
To our knowledge, there has been no case reported in the literature regarding concomitant percutaneous lead extraction and AngioVac removal of large vegetations. Patel et al 7 reported the successful use of the AngioVac cannula for the removal of large lead vegetations as a bridge to allow for percutaneous lead extraction in a separate session. In contrast, in our case, both vegetation removal and lead extraction were performed simultaneously. We believe our approach can further enhance procedural efficacy in removal of unwanted debris and reduce the risk of pulmonary embolism at the time of lead extraction.