case_images: PMC10751563_01
case_images: Fluoroscopy images during initial implantation of a cardiac resynchronization therapy-defibrillator 11 years before current presentation and chest x-ray image prior to the extraction procedure. (A) Venography showed a single appropriate branch vessel for cardiac resynchronization therapy implantation (white arrow). (B) Right anterior oblique view after implantation. (C) LAO view after implantation. (D) Chest x-ray image prior to the current extraction procedure. CRT-D, cardiac resynchronization therapy-defibrillator; CS, coronary sinus.
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case_images: Dislodgement or fracture of the CS lead initially implanted in the lateral cardiac vein on the LV basal segment was not definite on the chest x-ray (Figure 1).
case_images: Venography of the cardiac venous system after coronary sinus lead extraction. (A) After coronary sinus lead extraction, the proximal portion of the vessel (arrow) in which the old coronary sinus lead was previously located was not visualized by contrast injection. (B) The distal portion of the target vessel (arrow) was visualized by the retrograde flow (dashed arrow) of contrast via the connecting vessel. CS, coronary sinus; ICE, intracardiac echocardiography, LV, left ventricle; RV, right ventricle; TPM, temporary pacemaker.
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case_images: After CS lead extraction, however, the vessel in which the CS lead was previously located was not visualized by contrast injection (Figure 2A). Fortunately, however, the distal portion of the initial target vein was visualized by retrograde flow of contrast via the connecting vessel (Figure 2B).
case_images: The anti-dromic snare technique. (A) A 0.014'' guidewire was inserted into the middle cardiac vein and advanced retrograde into the target lateral vein via the connecting vessel. (B) The guidewire was further inserted back into the coronary sinus ostium. (C) The distal end of the guidewire was captured around the coronary sinus ostium using a snare. (D) The coronary sinus lead was inserted through the distal end of the guidewire and then advanced into the target vein over the guidewire, while both ends of the guidewire were under the control of the operator. (E) The coronary sinus lead was implanted into the same target lateral vein in which the extracted old coronary sinus lead was positioned. (F) Final separation between the coronary sinus and right ventricle leads was satisfactory in the LAO view. CS, coronary sinus; RV, right ventricle.
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case_images: First, a 0.014''x180 cm guidewire was inserted into the middle cardiac vein and advanced retrograde into the distal portion of the target vein via the connecting vessel (Figure 3A), guided by intermittent puffs of contrast. Then, the 0.014''x180 cm guidewire was further inserted back into the CS ostium (Figure 3B). The distal end of the guidewire was captured around the CS ostium using the EN Snare (Merit Medical, South Jordan, UT, USA), which was introduced via the sheath prepared for insertion of a new defibrillator lead (Figure 3C). Using a veno-venous loop of the guidewire, we were able to insert the new CS lead into the same target vein, overcoming some resistance, while both ends of the guidewire were under the control of the operator (Figure 3D and E). Subsequently, a new defibrillator lead was inserted at the apical mid-septum of the RV, with good separation between the CS and RV leads in the left anterior oblique (LAO) view (Figure 3F).