Inadvertent Transarterial Lead Placement in the Left Ventricle and Aortic Cusp: Percutaneous Lead Removal with Carotid Embolic Protection and Stent Graft Placement

BACKGROUND/PURPOSE Transarterial lead implantation in the left ventricle or aorta is a rare complication. Percutaneous lead removal is associated with significant thromboembolic and bleeding risk. We present two cases of lead removal from the left ventricle via the left subclavian artery with concurrent carotid embolic protection followed by stent graft placement in the subclavian artery. METHODS/RESULTS Patient 1 underwent prior pacemaker implant with atrial and ventricular active fixation leads positioned in the right coronary cusp and the left ventricle, respectively. Patient 2 had prior ICD implant with a single active fixation lead positioned in the left ventricular apex. Lead removal was performed in a hybrid operating room. Distal embolic filter wires were deployed in the carotid arteries following anticoagulation. Intravascular ultrasound of the left subclavian artery was performed and as the leads were withdrawn, a covered stent was deployed at the removal site. Final angiography demonstrated no evidence of embolic phenomena. Both patients underwent transvenous lead implantation followed by an uneventful postoperative clinical course. CONCLUSIONS Transarterial percutaneous lead removal may be safely performed using embolic filter protection of the cerebral circulation and stent graft placement of the arterial entry site.