A 20-year indwelling dual-coil passive-fixation ICD lead complicated by CIED pocket infection in an 85-year-old patient: a rare case report

Heart rhythm devices, known as implantable cardioverter-defibrillators, are life-saving machines that monitor the heart and deliver a shock if a dangerous rhythm occurs. Over time, these devices can become infected, a serious complication that requires the entire system to be removed to cure the patient. Removing the device is straightforward when it is new, but the task becomes a delicate and dangerous operation when the wires, or leads, have been inside the body for many years. As time passes, the body naturally builds layers of scar tissue around these wires, anchoring them tightly to the heart and blood vessels. The longer a wire stays in place, the more entrenched it becomes, making removal a high-stakes procedure where even a small slip could tear a blood vessel or damage the heart. This challenge is compounded when the patient is very elderly, as their blood vessels are often more fragile and less able to withstand the stress of surgery.

In a rare and complex case, doctors at Wuhan Asia Heart Hospital faced this exact scenario with an eighty-five-year-old man. He had a defibrillator lead that had been inside his body for twenty years, a duration that is exceptionally long for such a device. The lead was a specific type with two metal coils designed to hold it in place without active screws, a design that often encourages the body to grow thick, fibrous tissue around it. The patient developed an infection in the pocket where the device sits under the skin, a condition that necessitated the complete removal of the system. The medical team knew that extracting a wire left in place for two decades in an octogenarian would be incredibly difficult, but the situation presented a unique twist that made standard removal techniques impossible.

When the surgeons began the procedure, they attempted to use a laser sheath, a tool commonly used to slice through scar tissue. This tool requires a thin, stiff wire to be threaded through the hollow center of the old lead to guide the laser safely to the tip. However, as the team tried to pass this guide wire, they discovered that the inside of the lead was completely blocked. After twenty years, the inner channel had become clogged with debris and compressed by the surrounding scar tissue, preventing the guide wire from reaching the end of the lead. Without this guide, the laser sheath could not be used safely, as forcing it forward without a guide would risk cutting the blood vessel wall instead of the scar tissue. The team had to abandon the laser approach entirely to avoid causing a catastrophic injury.

Instead, the surgeons switched to a different mechanical tool, a rotating dilator sheath, which acts like a specialized drill that can cut through tough material while spinning. They carefully advanced this tool over the blocked lead, using a rotating blade at its tip to slice through the layers of hardened scar tissue that had encased the wire. The team worked in a slow, methodical fashion, cutting through the fibrous layers inch by inch while gently pulling back on the lead to keep it steady. This layer-by-layer dissection allowed them to free the lead from the heart and the blood vessels without leaving any fragments behind or damaging the surrounding structures. The entire operation lasted two and a half hours, and throughout the process, the patient's vital signs remained stable, with no tears in the heart or blood vessels.

Once the infected lead and device were successfully removed, the doctors had to decide how to protect the patient from future heart rhythm problems. The patient still had a high risk of dangerous heartbeats, but putting a new wire back into the veins was not a safe option. The risk of the new wire getting infected again was too high, and the patient did not need a device that could pace the heart for slow rhythms, which is the only reason a wire inside the heart is usually necessary. Consequently, the team implanted a subcutaneous defibrillator, a device that sits entirely under the skin without any wires entering the heart or blood vessels. This new system provides the same life-saving shock capability but eliminates the risk of deep vein infections and the difficulty of removing wires in the future.

The successful removal of this twenty-year-old lead in an eighty-five-year-old patient highlights the importance of having multiple tools and strategies available for complex medical cases. The outcome was not guaranteed, as the blockage inside the lead could not have been predicted before the surgery began. The medical team relied on a careful plan that included backup support from heart surgeons and continuous monitoring of the heart's function during the operation. By adapting their technique when the standard method failed, they were able to clear the infection and provide the patient with a safer, long-term solution. This case demonstrates that even in situations where the risks are extreme and the anatomy is heavily altered by time, a tailored approach can lead to a successful recovery.