Hybrid minimally invasive technique with the bidirectional rotational Evolution^® mechanical sheath for transvenous lead extraction: A collaboration between electrophysiologists and cardiac surgeons

Abstract

We report a case of a 63‐year‐old man referred for lead extraction with the bidirectional rotational Evolution® RL mechanical sheath because of systemic infection. As it was judged a “high‐risk” procedure, we opted for a “hybrid,” minimally invasive approach consisting in a minithoracotomic access. This technique is a feasible approach, and it might be a potential safer alternative in the most challenging transvenous lead extraction procedures.

Multicenter experience with the Evolution RL mechanical sheath for lead extraction using a stepwise approach: Safety, effectiveness, and outcome

“…One of the most recently developed mechanical techniques for TLE extraction is the mechanical sheath Evolution RL (Cook Medical) . The Evolution system comprises a powered sheath with a rotating tip that can cut through fibrous tissue, which significantly reduces the amount of traction and counter‐traction needed to extract the lead.…”

“…The second‐generation Evolution device has been redesigned to address these problems; it has a bidirectional rotational mechanism, which prevents lead wrapping, and a less aggressive tip, which may reduce the risk of damage to coexisting leads and vascular structures. Initial single‐center experiences with a limited number of patients yielded promising results with the second generation of the Evolution mechanical extraction device . Recently, an Italian multicenter registry with a large study population demonstrated that the Evolution RL device is an effective TLE tool with high success rates with long‐implanted leads .…”

“…Compression coil (One‐Tie, Cook Medical) is an additional tool to increase lead control as noted by less slippage of the locking stylet from within the lumen of the lead during maximal traction force. This enables improved lead control at the tip of a targeted lead and subsequent improved central support of extraction sheaths in the case of challenging extraction procedures . Finally, another additional tool is the SteadySheath Evolution Tissue Stabilization Sheath (Cook Medical), which was used in case of tenacious fibrotic adherences limiting the advance of the Evolution RL after several attempts and adjustments (Step 5).…”

“…Thus, “hand‐powered” mechanical rotational sheaths were developed as potential viable alternative to laser sheath especially in case of calcified fibrosis. The Evolution system has emerged as a mechanical TLE tool and few preliminary single center studies reported its safety and high efficacy (clinical success rate: 97.9–100%) using both the first‐ and second‐generation sheath (Evolution RL) . Recently, our group in a multicenter prospective study reported that the Evolution RL bidirectional rotational mechanical sheath is an effective and safe tool for extraction of chronically implanted leads without major complications and lead wrapping or lead damage .…”

“…Despite improvements, TLE is still a challenging procedure, especially when leads are chronically implanted, and is associated with potential life‐threatening complications . Recently, single‐center experiences and a multicenter registry have shown that Evolution sheath (Evolution RL, Cook Medical, Bloomington, IN, USA) with its bidirectional rotational mechanism and redesigned tip is an effective and safe hand‐powered mechanical sheath for the extraction of chronically implanted leads when advanced techniques are required. In addition to the Evolution RL sheath, tools by Cook Medical, supporting lead extraction procedures, including the Evolution Shortie RL, One‐Tie Compression Coil, and the SteadySheath Evolution Tissue Stabilization Sheath, were introduced in the market (http://www.cookmedical.com/lead-management) (Figure ).…”