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Ann Thorac Surg 2006;81:2304-2306
© 2006 The Society of Thoracic Surgeons

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Case report

Arteriovenous Fistula After Laser-Assisted Pacemaker Lead Extraction

Department of Cardiothoracic Surgery, New York-Presbyterian Hospital, Weill Cornell Medical Center, New York, New York

Accepted for publication June 27, 2005.

^_* Address correspondence to Dr Girardi, Cardiothoracic Surgery, Greenberg M-404, New York-Presbyterian Hospital, 525 East 68th St, New York, NY (Email: lngirard{at}med.cornell.edu).

	Abstract

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Acute arteriovenous fistulas have been reported after pacemaker lead extraction. We report a case of an arteriovenous fistula presenting 2 weeks after transvenous laser-assisted lead extraction.

	Introduction

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The incidence of pacemaker infections range from 0.5% to 7%, with Staphylococcus epidermidis being the most common offending organism in late infections [1–3]. The treatment of choice is an extraction of the pacemaker generator and leads. Although generator removal is a relatively simple procedure, lead extraction can be more difficult as they become encased in fibrotic tissue along the vessel wall [4]. The technique most often used for lead extraction is a transvenous, laser-assisted approach. Serious complications range from 0.6% to 3.3%, most of which are diagnosed in the immediate perioperative period [5]. These include perforation leading to a hematoma, hemothorax, or cardiac tamponade. Arteriovenous fistulas have also been reported during the perioperative period [4–6]. These are recognized during the procedure by the presence of chest or back pain, in addition to bright red blood flowing from around the sheath [4, 6]. This is the first report of a traumatic arteriovenous fistula presenting 2 weeks after laser-assisted pacemaker lead extraction.

An 84-year-old man, with a history of atrial fibrillation and dual chamber pacemaker placed in 1995, presented with erosion of the generator through the skin. The generator was removed and the leads were extracted with the aid of a 16-French Spectronetics transvenous Xenon-Chloride laser sheath (Spectranetics Corp, Colorado Springs, CO). Intermittent pulsations of laser energy using standard settings of 60 mJ with a rate of 40 pulses per second were used to extract the ventricular lead without complications. The same laser settings were used to extract the atrial lead; however, because the lead had preoperative integrity problems, it fractured intravascularly. A transfemoral, Cook approach was used to remove the remaining portion of the atrial lead. This was performed without complications, and the patient was discharged home. One week later the patient returned to have a new pacemaker placed on the contralateral side. Final cultures of the generator pocket and atrial lead showed the presence of diphtheroids.

Two weeks after the extraction, the patient had progressive dyspnea develop, and he was readmitted with congestive heart failure. On physical examination, he had left upper extremity edema with significant jugular venous distention. A new 3/6 holosystolic murmur was present at the left upper sternal border. A palpable thrill was felt over his precordium. Transthoracic echocardiography was unremarkable except for severe tricuspid regurgitation. Cardiac catheterization demonstrated nonobstructive coronary artery disease and an arteriovenous fistula from the left common carotid artery (LCCA) to the innominate vein (Fig 1). The patient underwent sternotomy and mediastinal exploration. An inflammatory mass was seen 3 cm above the origin of the LCCA. Proximal and distal control of both the LCCA and the innominate vein was obtained, and the patient was systemically anticoagulated with 100 U/Kg of heparin. An ascending aorta to the LCCA bypass was then performed with a 6-mm woven Dacron graft (Meadox Medical, Oakland, NJ). Carotid ischemic time was 6 minutes and there was no change in the patient's cerebral oxygen saturation during carotid reconstruction. The LCCA was ligated on both sides of the fistula. A venotomy was made in the innominate vein, and communication to the native carotid remnant was closed. The venotomy was then closed and normal venous flow was reestablished. The patient recovered without neurologic deficit or congestive heart failure and was discharged on postoperative day 6.

View larger version (181K): [in this window] [in a new window]   Fig 1. Angiogram demonstrating an arteriovenous communication between the left common carotid artery and innominate vein. Catheter originates from the descending aorta and enters the fistula. (LJV = left jugular vein; LSV = left subclavian vein.)

	Comment

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Lead extraction methods range from transvenous approaches to open procedures through a thoracotomy or a sternotomy. The transvenous approach is the most common and least invasive method currently available and includes the use of simple locking stylets, conventional countertraction with telescoping sheaths, and laser assisted countertraction [5]. The risk of complications increases with the degree of scar tissue around the leads, which is related to the length of time the leads are implanted [1]. Additional complications also correlate to the physician's experience, number of leads extracted per patient, and female gender [1, 7]. With locking stylets, complications are related to the inability to lock the catheter as close to the tip of the lead, which allows for direct traction to the tip. If gentle traction with this technique is unsuccessful, a telescoping sheath is placed over the locking sheath and advanced to the attachment point of the electrode, usually the myocardium. This provides countertraction, preventing inversion of the myocardium during traction of the lead. Complications with this technique are related to the degree of tension on the lead while advancing the sheath, and the inability to advance the sheath far enough to apply appropriate countertraction [1, 5].

New laser sheaths are currently being used to assist in disrupting the fibrous scars. In a randomized study comparing pacing lead extraction with the excimer sheath versus conventional sheath extraction in chronically implanted pacemaker leads, 94% of patients having laser-assisted sheath extraction had complete lead removal, whereas only 64% had complete lead removal with conventional sheath extraction methods. However, a majority of major complications occurred in the laser treated group. Three of these were life-threatening injuries and one was a fatal myocardial perforation. Although these were not the direct result of laser energy, additional precaution is necessary with conventional extraction methods after applying the laser sheath to break up fibrous scars [8].

A less common injury in lead extraction is the formation of an arteriovenous fistula [4–6]. The most common findings were the presence of excessive or bright red blood flowing from around the sheath, chest or back pain, cyanosis, tachypnea, and hemodynamic instability [4–6]. Immediate diagnosis and treatment is crucial. A simple chest roentgenogram may reveal a mediastinal hematoma or hemothorax. Angiography may be diagnostic, and occasionally, tamponade of the injury using an angioplasty balloon may be lifesaving. Definitive treatment may then be undertaken through more complex percutaneous or open surgical techniques.

This is the first described case of an arteriovenous fistula presenting 2 weeks after pacemaker lead extraction using a laser-assisted approach. Although there were no immediate complications as a result of the injury, the patient subsequently had a high output cardiac failure develop. After surgical repair with LCCA reconstruction, the patient has gone on to full recovery and remains symptom free.

	References

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1. Smith HD, Fearnot NE, Byrd CL, et al. Five-year experience with intravascular lead extraction PACE 1994;17:2016-2020.
2. Voet JG, Vandekerckhove YR, Muyldermans LL, Missault LH, Matthys LJ. Pacemaker lead infectionreport of three cases and review of the literature. Heart 1999;81(1):88-91.[Abstract/Free Full Text]
3. Manolis AS, Maounis TN, Vassilikos V, Chiladakis J, Melita-Manolis H, Cokkinos DV. Ancillary tools in pacemaker and defibrillator lead extraction using a novel lead removal system PACE 2001;24(3):282-287.
4. Kumins NH, Tober JC, Love CJ, et al. Arteriovenous fistulae complicating cardiac pacemaker lead extractionrecognition evaluation, and management. J Vasc Surg 2000;32:1225-1228.[Medline]
5. Bracke FA, van Gelder B, Meijer A. Arteriovenous fistula after injury to the left internal mammary artery during extraction of pacemaker leads with a laser sheath PACE 1999;22:833-834.
6. Cirillo RL, Fontaine AB. Iatrogenic brachiocephalic arteriovenous fistula; description of a fatal complication after cardiac pacemaker lead extraction J Vasc Interv Radiol 1998;9(6):1029-1030.[Medline]
7. Byrd CL, Wilkoff BL, Love CJ, et al. Intravascular extraction of problematic or infected permanent pacemaker leads1991–1996. US extraction database, MED Institute. PACE 1999;22:1348-1357.
8. Wilkoff BL, Byrd CL, Love CJ, et al. Pacemaker lead extraction with the laser sheathresults of the pacing lead extraction with the excimer sheath (PLEXES) trial. J Am Coll Cardiol 1999;33:1671-1676.[Abstract/Free Full Text]

This article has been cited by other articles:

				M. Novak, P. Dvorak, P. Kamaryt, B. Slana, and J. Lipoldova Autopsy and clinical context in deceased patients with implanted pacemakers and defibrillators: intracardiac findings near their leads and electrodes Europace, November 1, 2009; 11(11): 1510 - 1516. [Abstract] [Full Text] [PDF]

				W. Alayadhi, S. Wang, and R. G. Williams Arteriovenous fistula after laser-assisted extraction of an implantable defibrillator lead Interactive CardioVascular and Thoracic Surgery, February 1, 2009; 8(2): 243 - 244. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Charles A. Mack Leonard N. Girardi Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Milla, F. Articles by Girardi, L. N. Search for Related Content PubMed PubMed Citation Articles by Milla, F. Articles by Girardi, L. N. Related Collections Cardiac - other