Removal of a chronically implanted active-fixation coronary sinus pacing lead using the Cook Evolution(C) lead extraction sheath.

Case report An 80-year-old man with an implanted resynchronization therapy pacemaker device was referred to our institution in October 2011 to perform a transvenous lead and generator removal for a severe pocket infection. As left ventricular pacing lead, an unipolar activefixation coronary sinus (CS) lead (Attain StarFix 4195OTW,Medtronic Inc.), positioned in a lateral coronary vein, had been used. For lead removal, a venous lead entry site approach with a transvenous mechanical dilator technique, using polypropylene sheaths (Cook Intravascular Inc.) was used. However, the Attain StarFix lead could not be extracted with a sheath and a locking stylet, as its polyurethane lobes, expanded in the lateral coronary vein, could not be relaxed. We decided to try to mobilize the lobes with a 9F mechanical dilator sheath (Evolution, Cook Inc.), which was carefully advanced via the CS into the lateral coronary vein. Little movements back and forth, combined with several mechanical tip rotations of the Liberator sheath every 5 mm made it possible to reach and finally loose the tip of the StarFix lead. After fluoroscopic confirmation of a proper sheath position, the extraction of the complete lead, using continuous traction, could be accomplished (Figure 1). Immediately after the procedure, a discrete pericardial effusion was seen. This effusion disappeared without the need for pericardiocentesis within 3 days.