implantable cardioverter defibrillator ( icd ) implantation is performed at many centers in korea,1)2 ) however , icd lead extraction has not yet been reported .
we report our experience of icd lead extraction using locking stylet and polypropylene dilator sheath in a patient with recurrent inappropriate shocks due to lead fracture .
a 46-year - old man presented to our institution for evaluation of repeated , inappropriate , icd shocks .
icd ( single chamber , dual coils , vitruso dr d164awg , medtronic inc . , minneapolis , mn , usa ) was implanted for sustained monomorphic ventricular tachycardia associated with unstable hemodynamics and underlying systolic left ventricular dysfunction .
the ejection fraction of 30% was recorded two years ago at another hospital . during icd implantation
, ventricular fibrillation was induced by t - shock and successfully terminated by biphasic shock at 10 j. icd interrogation revealed 33 episodes of shock delivery due to noise sensing .
however , a definite break point of icd lead was not detected on chest x - ray .
icd therapy was switched off based on a clinical diagnosis of icd lead fracture , and the patient was transferred to our hospital .
the icd lead ( sprint quattro 6944 , medtronic inc . ) was tined , and the diameter of lead tip and shaft ( comprising shock coil ) was 2.7 mm .
icd lead extraction was performed with support from the cardiac surgery team . following routine preparation for generator removal ,
the disconnected lead was tested again to exclude connection problem between icd lead and the generator , which showed high impedance over 2,500 ohms .
lead extraction was performed after confirming icd lead fracture . a locking stylet ( liberator locking stylet 016 - 032 , cook vascular inc . ,
vandergrift , pn , usa ) was inserted into the central core of the icd lead to prevent lead disruption .
a 12 fr ( 4 mm ) polypropylene dilator sheath ( byrd dilator sheath sets , cook vascular inc . )
mild traction force was applied to the locking stylet to straighten the alignment of the icd lead and the dilating sheath .
the dilator sheath was advanced with bidirectional ( clockwise and counter - clockwise ) rotation to dissect adhesive fibrous bands formed around the icd lead .
when the dilator sheath was placed 1 - 2 cm below the tip of right ventricular ( rv)-lead , the locking stylet was pulled gently with gradually increasing traction forces .
the icd lead and dilator sheath were successfully removed without evidence of lead fragments remaining in the right ventricle ( fig .
there was no evidence of major complications , such as hemopericardium , hemothorax , and myocardial inversion .
after confirming successful icd lead extraction , a new icd lead was inserted into right ventricle followed by skin closure .
pacemaker or icd rv - lead extraction is a high risk procedure with a morbidity of 1.4 - 2.5%.3)4 ) fibrous tissues encapsulate implanted leads and cause adhesion to major veins , the right atrial or the ventricular wall.5 ) major complications such as hemopericardium , hemothorax and death occur during fibrous tissues dissection around the implanted leads.6 ) incomplete lead removal or procedure failure is another clinical problem that occurs in 7 - 13.2% of cases.3)4 ) if an infected lead is retained , the risk of treatment failure with antibiotics will be very high.7 ) even non - infected lead fragment may cause embolic complications.8)9 ) therefore , various extraction techniques have been tried to improve the success rate of complete lead removal .
they include direct traction with rotational forces,10 ) traction with locking stylet,11 ) counter - traction with dilating sheath,3)4 ) femoral workstation,12 ) laser sheath,13 ) and electrosurgical sheath.14 ) traction and counter - traction using locking stylet and dilating sheath is a conventional technique for pacemaker and icd lead extraction .
it has been proven to be effective and safe in clinical trials.3)4 ) although newly developed techniques such as electrosurgical or laser sheath are in clinical use , they have not been introduced in korea , and the conventional technique using locking stylet and dilator sheath is still useful if performed by experienced operators.14 ) the authors tried 25 pacemaker and one icd lead extractions associated with lead malfunction or infection since 2004 .
of the 26 cases , 24 cases were successfully managed with the conventional traction and counter - traction technique using locking stylet and dilator sheath . in the two failed attempts , the operators could not advance the dilator sheath to the icd lead tip due to severe fibrous adhesion at the subclavian vein and in the superior vena cava .
of the 24 successful cases , open heart surgery was performed in one case due to cardiac tamponade following complete pacemaker ventricular lead extraction .
icd lead extraction is known to have higher complication rate than pacemaker lead extraction.6 ) however , it can be removed successfully with the same techniques . to our knowledge , this is the first icd lead extraction case reported in korea .
 a 46-year - old man presented to our institution with inappropriate implantable cardioverter - defibrillator ( icd ) shock delivery . 
 the icd ( single chamber , dual shock coils ) was implanted for sustained monomorphic ventricular tachycardia with unstable hemodynamics and underlying systolic left ventricular dysfunction . 
 icd interrogation revealed recurrent episodes of icd shock due to noise sensing and increased impedance of right ventricular - lead . with the impression of lead fracture 
 , icd lead extraction was performed . 
 the fractured icd lead was completely removed by traction of locking stylet and counter - traction of polypropylene dilator sheath . 
 a new lead was inserted and the patient was discharged without complications after 2 days . to our knowledge , this is the first report on icd lead extraction by conventional traction and counter - traction technique in korea . 
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