Facilitation of transvenous lead extraction using the TWIX technique: simultaneous extraction of two leads through a single sheath

Background

Transvenous lead extraction (TLE) is technically demanding procedure that carries risk of serious complications. In many cases multiple leads require removal.

Fibrous adhesions frequently bind the leads together, and attempting to separate them with a cutting sheath may increase procedural complexity and risk—particularly with longer dwell times.

Purpose

To describe a series of TLE procedures, using the "TWIX technique", in which two pacemaker leads are extracted together, through a single sheath.

Methods

Four patients underwent TLE due to local or systemic infection: two with dual-chamber pacemakers, one with an ICD and one with a CRTD.

In all cases, the pair extracted together consisted of a right atrial (RA) and a right ventricular (RV) pacemaker lead with passive fixation (one case had an active-fixation RA lead). Lead dwell time ranged from 9–21 years (median 14.8 years).

An external sheath was advanced over both leads, each secured with a locking stylet. A mechanical rotating sheath (Tight Rail, 14 F) was used in two cases, and a laser sheath (16 F) in the other two.

ICD defibrillation leads (two patients) and coronary sinus lead (one patient) were extracted separately

Results

All targeted leads were successfully extracted without clinically significant cardiac or vascular injury and without lead disruption. In three cases, the RA and RV leads were removed in block. Prominent inter-lead adhesions were observed (Figure). In one case, the RA lead disengaged first, and further sheath advancement was required to extract the RV lead. No significant adhesions between leads were noted in this case.

Conclusion

To our knowledge, this is the first report of a novel "TWIX technique" for simultaneous extraction of two pacemaker leads through a single sheath. In this small series of long-dwell leads, the approach was safe and effective, reduced the need for additional sheath advancement. This may significantly facilitate the procedure, shorten procedure time, and prevent vascular and cardiac tissue injury.Leads, with 21 year dwelling time