Impact of obesity on acute complications of catheter ablation for cardiac arrhythmia

BACKGROUND

The prevalence of obesity is increasing. However, data on the periprocedural complication rate of catheter ablation for arrhythmia in patients stratified by body mass index (BMI) is scarce.

METHODS AND RESULTS

This study included 1000 consecutive patients (age 62.0±14.4 years) undergoing catheter ablation for cardiac arrhythmia. The primary study endpoint was any periprocedural major complication (cardiac tamponade, pseudoaneurysm, arteriovenous fistula, transient ischemic attack, stroke, valve damage, myocardial infarction or death). The mean BMI was 27.6±5.1 kg/m² and the majority of patients were overweight (BMI 25.0-29.9 kg/m² , 43.4%). A BMI of 30.0-34.9 kg/m² (Class I obesity) was present in 177 (17.7%) of patients, a BMI of 35.0-39.9 kg/m² (Class II obesity) in 67 (6.7%) and a BMI ≥40 kg/m² (Class III obesity) in 16 (1.6%). There were 31 major complications (3.1%) and one fatality (0.1%) due to terminal heart failure in a patient undergoing palliative ventricular tachycardia ablation. There was no significant impact of the BMI on the rate of major complications (p= 0.495). Compared to normal weight patients, odds ratios for complications in overweight patients, as well as class I, II and III obesity were 1.1 (95% confidence interval (CI) 0.8; 1.7), 1.3 (CI 0.6; 2.6), 1.4 (CI 0.5; 4.1) and 1.6 (CI 0.4; 6.3), respectively. Radiation exposure and procedure duration were significantly increased in obese patients (p<0.001 and p=0.001 respectively).

CONCLUSION

In this study, obesity did not have a significant impact on the incidence of periprocedural complications after CA for cardiac arrhythmia. This article is protected by copyright. All rights reserved.

Thirty-day outcomes of the Cardioband tricuspid system for patients with symptomatic functional tricuspid regurgitation: The TriBAND study

BACKGROUND

Severe tricuspid regurgitation (TR) has limited treatment options and is associated with high morbidity and mortality.

AIMS

We evaluated the safety and effectiveness of the Cardioband tricuspid valve reconstruction system from the ongoing European single-arm, multicentre, prospective TriBAND post-market clinical follow-up study.

METHODS

Eligible patients had chronic symptomatic functional TR despite diuretic therapy and were deemed candidates for transcatheter tricuspid repair by the local Heart Team.

RESULTS

Sixty-one patients had ≥severe functional TR. At baseline, 85% of patients were in NYHA Class III-IV, 94% had ≥severe TR (core laboratory-assessed) with 6.8% EuroSCORE II and 53% LVEF. Device success was 96.7%. At discharge, 59% (p<0.001) of patients achieved ≤moderate TR and 78% had at least one grade TR reduction. At 30 days, all-cause mortality and composite MAE rates were 1.6% and 19.7%, respectively; septolateral annular diameter was reduced by 20%, where 69% of patients achieved ≤moderate TR and 85% of patients had at least one grade TR reduction (all p<0.001). Mid-RVEDD, RA volume, and IVC diameter decreased by 10% (p=0.005), 21% (p<0.001), and 11% (p=0.022), respectively; 74% were in NYHA Class I-II (p<0.001) with improvements in overall KCCQ score by 17 points (p<0.001).

CONCLUSIONS

In the TriBAND study, the Cardioband tricuspid system demonstrated favourable outcomes at discharge and 30 days in a challenging patient population with symptomatic ≥severe functional TR. Results showed significant reductions in annular diameter and TR severity, accompanied by early evidence of right heart remodelling and improvements in functional status and quality of life.

Study design and rationale of the pAtients pResenTing with cOngenital heaRt dIseAse Register (ARTORIA-R)

Aim

Due to improved therapy in childhood, many patients with congenital heart disease reach adulthood and are termed adults with congenital heart disease (ACHD). ACHD often develop heart failure (HF) as a consequence of initial palliative surgery or complex anatomy and subsequently require advanced HF therapy. ACHD are usually excluded from trials evaluating heart failure therapies, and in this context, more data about heart failure trajectories in ACHD are needed to guide the management of ACHD suffering from HF.

Methods and results

The pAtients pResenTing with cOngenital heaRt dIseAse Register (ARTORIA‐R) will collect data from ACHD evaluated or listed for heart or heart‐combined organ transplantation from 16 countries in Europe and the Asia/Pacific region. We plan retrospective collection of data from 1989–2020 and will include patients prospectively. Additional organizations and hospitals in charge of transplantation of ACHD will be asked in the future to contribute data to the register. The primary outcome is the combined endpoint of delisting due to clinical worsening or death on the waiting list. The secondary outcome is delisting due to clinical improvement while on the waiting list. All‐cause mortality following transplantation will also be assessed. The data will be entered into an electronic database with access to the investigators participating in the register. All variables of the register reflect key components important for listing of the patients or assessing current HF treatment.

Conclusion

The ARTORIA‐R will provide robust information on current management and outcomes of adults with congenital heart disease suffering from advanced heart failure.

Safety and efficacy of transvenous lead extraction of very old leads

OBJECTIVES

Transvenous lead extraction using mechanical rotational- or laser sheaths is an established procedure. Lead dwell time has been recognized as a risk factor for extraction failure and procedure-related complications. We therefore investigated the safety and efficacy of transvenous extraction of leads with an implant duration of more than 10 years.

METHODS

Between January 2013 and March 2017, a total of 403 patients underwent lead extraction in 2 high-volume lead extraction centres. One hundred and fifty-four patients with extraction of at least 1 lead aged over 10 years were included in this analysis. Laser lead extraction was the primary extraction method, with additional use of mechanical rotational sheaths or femoral snares, if necessary. All procedural- and patient-based data were collected into a database and retrospectively analysed.

RESULTS

Mean patient's age was 65.8 ± 15.8 years, 68.2% were male. Three hundred and sixty-two leads had to be extracted. The mean lead dwell time of treated leads was 14.0 ± 6.1 years. Complete procedural success was achieved in 91.6% of cases, while clinical success was achieved in 96.8%. Failure of extraction occurred in 3.2%. Leads that could not be completely removed had a significantly longer lead dwell time (18.2 vs 13.2 years; P = 0.016). Additional mechanical rotational sheaths or femoral snares were used in 26 (16.9%) patients. Overall complication rate was 4.6%, including 5 (3.3%) major and 2 (1.3%) minor complications. There was no procedure-related mortality.

CONCLUSIONS

Transvenous lead extraction in leads aged over 10 years is safe and effective when performed in specialized centres and with use of multiple tools and techniques. Leads that could not be completely extracted had a statistically significant longer lead dwell time.

Clinical impact of intervention strategies after failed transcatheter mitral valve repair

AIMS

Failure of transcatheter mitral valve repair (fTMVR) therapy has a decisive prognostic influence, and complex retreatment is of higher risk. The aim of this analysis was to evaluate the survival outcome following percutaneous procedures and surgery after unsuccessful TMVR interventions for different aetiologies.

METHODS AND RESULTS

Of 824 consecutive patients who had been treated with the MitraClip device at our institution, between September 2009 and May 2019, 63 (7.6%) symptomatic patients with therapy failure and persistent or recurrent mitral regurgitation (MR) underwent reinterventions. An outcome analysis for primary (PMR) and secondary mitral regurgitation (SMR) and subsequent percutaneous versus surgical treatment was carried out. MitraClip reinterventions were performed in 36 patients (57.1%; n=26 SMR, n=10 PMR), while 27 (42.9%; n=13 SMR, n=14 PMR) underwent open heart surgery. Surgical patients with PMR showed lower mortality than patients with SMR (p<0.0001) and ReClip patients with PMR (p=0.073). Atrial fibrillation (HR 2.915, 95% CI: [1.311, 6.480]), prior open heart surgery (2.820 [1.215, 6.544]) and chronic obstructive pulmonary disease (2.506 [1.099, 5.714]) increased the risk of death. The level of post-interventional MR had no relevant impact on survival.

CONCLUSIONS

We conclude that, after SMR and failed TMVR, reclipping is an appropriate treatment option for symptomatic patients. For PMR patients, surgery must be favoured over a reclipping procedure. However, patients with atrial fibrillation, prior open heart surgery and chronic obstructive pulmonary disease are at risk of reduced survival after reinterventions.

Safety and efficacy of transvenous lead extraction in octogenarians using powered extraction sheaths

BACKGROUND

In the aging population equipped with cardiac implantable electronic devices, an increasing number of octogenarians require lead extractions. This patient population is often considered as a high-risk group for surgical procedures. We, therefore, investigated the safety and efficacy of transvenous lead extraction in octogenarians using powered extraction sheaths.

METHODS

Between January 2013 and March 2017, 403 patients underwent lead extraction at two high-volume lead extraction centers. A total of 71 octogenarians were treated with laser lead extraction and were included in this analysis. Primary extraction method was laser lead extraction, with additional use of mechanical rotational sheaths or femoral snares, if necessary. Patient-based and procedural data were collected and analyzed retrospectively.

RESULTS

Mean age was 83.5 ± 3.3 years, 64.7% were males. A total of 152 leads were extracted. The mean lead dwell time of treated leads was 10.2 ± 5.2 years. Complete procedural success rate was 92.9%, while clinical success was achieved in 98.6%. Failure of extraction occurred in one patient (1.4%). In six (7.7%) patients, additional mechanical rotational sheaths or femoral snares were used. Overall complication rate was 4.2%, including one (1.4%) major (RA perforation) and two (2.8%) minor complications. No procedure-related mortality was observed in any of the patients.

CONCLUSION

Transvenous lead extraction in octogenarians with old leads is safe and effective when performed in experienced centers. Patient's age should therefore not be considered as contraindication for lead extraction using powered extraction sheaths.

Benefits of routine prophylactic femoral access during transvenous lead extraction

BACKGROUND

The number of patients requiring lead extraction has been increasing in recent years. Despite significant advances in operator experience and technique, unexpected complications may occur. Prophylactic placement of femoral sheaths allows for immediate endovascular access for emergency procedures and may shorten response time in the event of complications.

OBJECTIVE

The purpose of this study was to assess the benefits of routine prophylactic femoral access in patients undergoing transvenous lead extraction (TLE) and to evaluate the methods, frequency, and efficacy of the emergency measures used in those patients.

METHODS

We conducted a retrospective analysis of patients who underwent TLE from January 2012 to February 2019. The data were analyzed with regard to procedural complications and deployment of emergency measures via femoral access.

RESULTS

Two hundred eighty-five patients (mean age 65.3 ± 15.5 years) were included in the study. Median lead dwell time was 84 months (interquartile range 58-144). Overall complication rate was 4.2% (n = 12), with 1.8% major complications (n = 5). Clinical success rate was 97.2%. Procedure-related mortality was 1.1% (n = 3). Femoral sheaths were actively engaged in 9.1% (n = 26) of cases. Deployment of snares was the most common intervention (n = 10), followed by prophylactic (n = 6) or emergency placement (n = 1) of occlusion balloons, temporary pacing (n = 3), venous angioplasty (n = 3), diagnostic venography (n = 3), and extracorporeal membrane oxygenation (n = 1). We did not observe any femoral vascular complications due to prophylactic sheath placement.

CONCLUSION

Routine prophylactic placement of femoral sheaths shortens response time and quickly establishes control in the event of various complications that may occur during TLE procedures.

Performance and outcome of the subcutaneous implantable cardioverter-defibrillator after transvenous lead extraction

AIMS

The subcutaneous cardioverter-defibrillator (S-ICD) may be a valuable option in patients after successful transvenous lead extraction (TLE) without indication for pacemaker therapy and persistent risk of sudden cardiac death. The aim of this study was to evaluate device performance, postoperative outcome, and safety in patients who received a S-ICD after TLE compared to patients who underwent de-novo S-ICD implantation.

METHODS

A retrospective analysis of all patients included into our institution's S-ICD database between September 2010 and May 2019 was conducted.The patients were divided in two groups, depending on whether they had received their S-ICD after TLE (n = 31) or de-novo (n = 113).

RESULTS

The TLE group was significantly older with a mean age of 54.3 ± 15.7 versus 46.7 ± 14.4 years; p = .007. Leading S-ICD indication in the TLE group was previous infection (50%), whereas in the de-novo group the S-ICD was primarily chosen due to young patient age (74.6%). Median duration of follow-up was 527.0 versus 472.5 days, respectively; p = .576. Most common complication during follow-up was inappropriate ICD therapy (12.9% vs. 13.3%); p = 1.000. Pocket erosion/infection occurred in 3.2% versus 3.5% with no reported cases of systemic (re-)infection in either group; p = 1.000. All-cause mortality was low (6.2% vs. 2.7%) and entirely unrelated to S-ICD implantation or the device itself; p = .293.

CONCLUSION

The S-ICD is a safe and effective alternative for patients after TLE with very similar results regarding device performance and postoperative outcome, when compared to patients who underwent de-novo S-ICD implantation.

Probability of sinus rhythm conversion and maintenance in cardiac resynchronization therapy patients with atrial fibrillation during 5-year follow-up

INTRODUCTION

There is a high prevalence of atrial fibrillation (AF) in patients with heart failure presented for cardiac resynchronization therapy (CRT). It remains unclear whether an atrial lead should be implanted in these patients. We, therefore, analyzed outcomes and course of rhythm in AF patients undergoing CRT implantation during long-term follow-up.

METHODS AND RESULTS

Between 2004 and 2018, 328 consecutive patients with a history of AF receiving CRT implantation were included in this study. 132 patients had preoperatively paroxysmal AF (px-AF), while 70 and 126 patients had persistent AF (ps-AF) and long-standing persistent AF (lp-AF), respectively. The outcome data were collected in our institutional database and analyzed retrospectively. Two hundred and seventy-seven patients received an atrial lead at the time of implantation, nine during follow-up. No major lead implantation-associated complications were observed. In patients with px-AF, sinus rhythm (SR) was present in 78.8% at admission, 95.5% (p < .001) at discharge, and 85.7% (p = .965) after 5 years. In ps-AF patients SR was present in 28.6%, 91.4% (p < .001) and 69.7% (p < .001), while all lp-AF patients showed AF at admission and had SR rate of 50.8% (p < .001) at discharge and 44.1% after 5 years (p < .001).

CONCLUSION

We observed a high rate of conversion and long-term persistence of SR in AF patients undergoing CRT implantation. Due to the low rate of lead implantation-associated complications and the high successful SR conversion rates, we recommend the implantation of an atrial lead in CRT patients with AF.

1255Comprehensive analysis of pacemaker patients with and without abandoned leads undergoing transvenous lead extraction: A GALLERY subgroup analysis

OnBehalf

GALLERY investigators

Background

The number of cardiac implantable electronic device (CIED)-associated complications such as infection, lead dysfunction or thrombotic events is continuously rising and thus making transvenous lead extraction (TLE) an ever more needed procedure in clinical practice today. Patients with abandoned leads represent a special cohort with a potentially higher susceptibility to CIED-related infections and vascular complications. Moreover, according to literature abandoned leads seem to be associated with more procedural complications and mortality during TLE. 

Aim

 

The aim of this study was to provide an insight on safety, procedural outcome and risk prediction on pacemaker patients with abandoned leads undergoing TLE from the largest national laser-sheath registry to date.

Methods + Results:

We conducted a retrospective analysis of the GALLERY database, which collected 2533 patients undergoing TLE in Germany between 2013 and 2017. Out of 903 pacemaker patients, who underwent TLE, 226 patients (25.0%) with abandoned leads were identified. Those patients had a higher number of leads per patient (3.2 ± 0.8 vs. 1.9 ± 0.3; ns) and longer lead dwell-times (168.0 ± 89.7 vs. 123.0 ± 69.2 months; p &lt; 0.0001) compared to pacemaker patients without abandoned leads. There were no differences in age (71.5 vs. 72.3 years; ns), body mass index (26.5 ± 4.5 vs. 26.78 ± 4.8 kg/m2; ns) or gender distribution (69.0 vs. 66.5% male; ns). Leading indication for TLE was device infection with no difference between groups (79.7 vs 77.8 %; ns). There were no differences in terms of pacemaker dependency, length of hospitalization or comorbidities. Patients with abandoned leads had longer procedure times (112.0 ± 69.0 vs. 86.4 ± 53.0 minutes; p &lt; 0.0001) and a higher incidence of procedural complications (6.6 vs. 3.1%; p = 0.03), but there were no differences in neither procedural and clinical success rates (96.5 vs. 97.3%; ns), nor all-cause mortality (1.33 vs. 2.66%; ns). Multivariate logistic regression revealed abandoned leads (OR 2.1, CI 1.0-4.4, p = 0.04) and female gender (OR 2.4, CI 1.2-4.9, p = 0.02) as independent predictors for procedural complications. Systemic infection (OR 5.4, CI 2.0-14.8, p = 0.001) and chronic kidney disease (OR 4.0, CI 1.5-10.7, p = 0.007) were strong predictors for all-cause mortality in patients with indwelling pacemaker. Patient age &gt; 75 years (OR 3.9, CI 2.7-5.6, p &lt; 0.0001) and a lead dwell-time &gt; 10 years (OR 1.6, CI 1.1-2.2, p = 0.01) were identified as risk factors for an infectious cause for TLE. 

Conclusion

Abandoned leads are frequently encountered in pacemaker patients undergoing TLE and pose an important risk factor for procedural complications. Systemic CIED-related infections are the strongest driver of mortality in this patient cohort and urgently call for further improvements in early diagnosis and prevention.

Five-year follow-up of transvenous and epicardial left ventricular leads: experience with more than 1000 leads

OBJECTIVES

Transvenous coronary sinus leads are considered to be the gold standard for cardiac resynchronization therapy (CRT). However, in patients with abnormal coronary vein anatomy, the epicardial leads can be an alternative. Data comparing durability and performance of these 2 lead types are limited. In order to provide clarity, we investigated patients receiving CRT system in our centre.

METHODS

One thousand and fifty-three consecutive patients scheduled for CRT implantation were retrospectively analysed. From these, 895 received transvenous coronary sinus and 158 epicardial left ventricular (LV) leads. Lead-specific as well as LV functional parameters have been evaluated in 60 months' follow-up.

RESULTS

Technical characteristics (pacing threshold, impedance and sensing) of both lead types remained stable during the whole observation period. Whereas an early revision (<6 month) was noted in 5.4% of transvenous leads, no reintervention has been necessary for epicardial leads. During the 5-year observation period, a lead revisions rate of 10.2% for transvenous leads and 1.9% for epicardial leads were detected. Regarding CRT efficacy, excellent results were achieved for both electrode types. In both groups, a statistically significant reduction of New York Heart Association class (2.85-2.13 and 2.96-2.09), increase in left ventricular ejection fraction (24.6-32.6% and 27.2-34.6%), reduction of left ventricular end-systolic diameter/left ventricular end-diastolic diameter and reduction in degree of mitral valve insufficiency could be observed over the time.

CONCLUSIONS

Our data demonstrate safety and functional efficacy of both transvenous and epicardial leads. Moreover, in long-term follow-up, a commendable durability and performance were found for both lead types. Thus, epicardial leads represent a good alternative when transvenous implantation fails.

Transvenous lead extraction after heart transplantation: How to avoid abandoned lead fragments

BACKGROUND

Many patients awaiting heart transplantation (HTX) have a cardiac implantable electronic device (CIED). Lead removal is often still a part of the HTX procedure. Abandoned lead fragments carry a risk for infections and prohibit magnetic resonance imaging (MRI) imaging. This study evaluated the concept of an elective lead management algorithm after HTX.

METHODS AND RESULTS

Between 2009 and 2018, 102 consecutive patients with previously implanted CIED underwent HTX. Lead removal by manual traction during HTX was performed in 74 patients until December 2014. Afterward, treatment strategy was changed and 28 patients received elective lead extraction procedures in a hybrid operating room (OR) using specialized extraction tools. Total of 74 patients with 157 leads underwent lead extraction by manual traction during HTX. The mean lead age was 32.3 ± 38.7 months. Postoperative X-ray revealed abandoned intravascular lead fragments in 31(41.9%) patients, resulting in a complete lead extraction rate of only 58.1%. The high rate of unsuccessful lead extractions led to the change in the extraction strategy in 2015. Since then, HTX was performed in 28 CIED patients. In those patients, 64 leads with a mean lead age of 53.8 ± 42.8 months were treated in an elective lead extraction procedure. No major or minor complications occurred during lead extraction. All leads could be removed completely, resulting in a procedural success rate of 100%.

CONCLUSION

Our results demonstrate that chronically implanted leads should be removed in an elective procedure, using appropriate extraction tools. This enables complete lead extraction, which reduces the infection risk in this patient population with the necessity for permanent immunosuppressive therapy and allows further MRI surveillance.

The Bridge Occlusion Balloon for Venous Angioplasty in Superior Vena Cava Occlusion

The Bridge Occlusion Balloon is a compliant balloon, specifically designed for temporary Superior vena cava occlusion in case of Superior Vena Cava laceration during lead extraction procedures.

We here report the first case, using Bridge Occlusion Ballon for a venous angioplasty in a patient with dysfunctional pacemaker leads and symptomatic Superior Vena Cava occlusion. After successful lead extraction, venography was showing a narrow venous canal. Therefore, venous angioplasty using the Bridge balloon was performed.

Especially for high-risk lead extraction cases in patients with Superior Vena Cava stenosis, the Bridge Occlusion Ballon might be used as a combination of a safety-net in case of Superior Vena Cava perforation and for Superior Vena Cava angioplasty.

Misplaced Ventricular Lead via an Atrial Septal Defect-Percutaneous Extraction

Background  Necessity for lead removal in this case was after 12 years due to mitral valve regurgitation caused by retraction of the posterior leaflet by the inadvertently misplaced lead.

Case Description  This history describes a 45-year-old woman with history of multiple cardiac operations at young age with an abandoned defibrillator lead via a patent atrial septal defect. Lead extraction was performed with first described use of rotational dilating sheaths to reduce emboli risk, hoping to avoid a fourth surgical procedure with high risk.

Conclusions  Percutaneous lead removal using rotational sheaths is possible even for misplaced leads after long-time intervals with acceptable operative risk.

Long-term efficacy and safety of radiofrequency catheter ablation of atrial fibrillation in patients with cardiac implantable electronic devices and transvenous leads

INTRODUCTION

Long-term efficacy and safety are uncertain in patients with cardiac implantable electronic devices (CIED) and transvenous leads (TVL) undergoing radiofrequency catheter ablation of atrial fibrillation (AF). Thus, we assessed the outcome of AF ablation in those patients during long-term follow-up using continuous atrial rhythm monitoring (CARM).

METHODS AND RESULTS

A total of 190 patients (71.3 ± 10.7 years; 108 (56.8% men) were included in this study. At index procedure 81 (42.6%) patients presented with paroxysmal AF and 109 (57.4%) with persistent AF. The ablation strategy included pulmonary vein isolation in all patients and biatrial ablation of complex fractionated electrograms with additional ablation lines, if appropriate. AF recurrences were assessed by CARM- and CIED-related complications by device follow-up. After a mean follow-up of 55.4 ± 38.1 months, freedom of AF was found in 86 (61.4%) and clinical success defined as an AF burden less than or equal to 1% in 101 (72.1%) patients. Freedom of AF was reported in 74.6% and 51.9% (P = 0.006) and clinical success in 89.8% and 59.3% (P < 0.001) of patients with paroxysmal and persistent AF, respectively. In 3 of 408 (0.7%) ablation procedures, a TVL malfunction occurred within 90 days after catheter ablation. During long-term follow-up 9 (4.7%) patients showed lead dislodgement, 2 (1.1%) lead fracture, and 2 (1.1%) lead insulation defect not related to the ablation procedure.

CONCLUSION

Our findings using CARM demonstrate long-term efficacy and safety of radiofrequency catheter ablation of AF in patients with CIED and TVL.

The Bridge Occlusion Balloon as a safety net in a high-risk transvenous lead extraction procedure

Injuries to the superior vena cava (SVC) during transvenous lead extraction (TLE) procedures are a rare but life-threatening complication. The Bridge Occlusion Balloon (BOB) is specifically designed for temporary SVC occlusion in TLE procedures. We report the first case of a 27-year-old man using the BOB as a safety net in a high-risk TLE procedure. This patient, with a congenitally corrected transposition of the great arteries and a third-degree atrioventricular block, presented with 4 dysfunctional pacemaker leads, venous stenosis and the necessity for a new pacemaker system. The leads were implanted for 10 and 19 years. The BOB was placed with a radiopaque marker at the cavoatrial junction and was inflated with 46 ml of an 80/20 saline/contrast agent mixture. An angiography was performed to confirm SVC occlusion. With the deflated balloon in place, the TLE procedure with laser and mechanical sheaths was performed. Successful extraction of 2 dysfunctional leads, as well as venous recanalization, for the new right atrial and right ventricular lead implantation was achieved. We have shown the feasibility of using powered extraction sheaths with a deflated BOB in place. This allows for immediate balloon inflation, in case of an SVC perforation.