implantable cardioverter defibrillator ( icd ) implantation is performed at many centers in korea,1)2 ) however , icd lead extraction has not yet been reported . we report our experience of icd lead extraction using locking stylet and polypropylene dilator sheath in a patient with recurrent inappropriate shocks due to lead fracture . a 46-year - old man presented to our institution for evaluation of repeated , inappropriate , icd shocks . icd ( single chamber , dual coils , vitruso dr d164awg , medtronic inc . , minneapolis , mn , usa ) was implanted for sustained monomorphic ventricular tachycardia associated with unstable hemodynamics and underlying systolic left ventricular dysfunction . the ejection fraction of 30% was recorded two years ago at another hospital . during icd implantation , ventricular fibrillation was induced by t - shock and successfully terminated by biphasic shock at 10 j. icd interrogation revealed 33 episodes of shock delivery due to noise sensing . however , a definite break point of icd lead was not detected on chest x - ray . icd therapy was switched off based on a clinical diagnosis of icd lead fracture , and the patient was transferred to our hospital . the icd lead ( sprint quattro 6944 , medtronic inc . ) was tined , and the diameter of lead tip and shaft ( comprising shock coil ) was 2.7 mm . icd lead extraction was performed with support from the cardiac surgery team . following routine preparation for generator removal , the disconnected lead was tested again to exclude connection problem between icd lead and the generator , which showed high impedance over 2,500 ohms . lead extraction was performed after confirming icd lead fracture . a locking stylet ( liberator locking stylet 016 - 032 , cook vascular inc . , vandergrift , pn , usa ) was inserted into the central core of the icd lead to prevent lead disruption . a 12 fr ( 4 mm ) polypropylene dilator sheath ( byrd dilator sheath sets , cook vascular inc . ) mild traction force was applied to the locking stylet to straighten the alignment of the icd lead and the dilating sheath . the dilator sheath was advanced with bidirectional ( clockwise and counter - clockwise ) rotation to dissect adhesive fibrous bands formed around the icd lead . when the dilator sheath was placed 1 - 2 cm below the tip of right ventricular ( rv)-lead , the locking stylet was pulled gently with gradually increasing traction forces . the icd lead and dilator sheath were successfully removed without evidence of lead fragments remaining in the right ventricle ( fig . there was no evidence of major complications , such as hemopericardium , hemothorax , and myocardial inversion . after confirming successful icd lead extraction , a new icd lead was inserted into right ventricle followed by skin closure . pacemaker or icd rv - lead extraction is a high risk procedure with a morbidity of 1.4 - 2.5%.3)4 ) fibrous tissues encapsulate implanted leads and cause adhesion to major veins , the right atrial or the ventricular wall.5 ) major complications such as hemopericardium , hemothorax and death occur during fibrous tissues dissection around the implanted leads.6 ) incomplete lead removal or procedure failure is another clinical problem that occurs in 7 - 13.2% of cases.3)4 ) if an infected lead is retained , the risk of treatment failure with antibiotics will be very high.7 ) even non - infected lead fragment may cause embolic complications.8)9 ) therefore , various extraction techniques have been tried to improve the success rate of complete lead removal . they include direct traction with rotational forces,10 ) traction with locking stylet,11 ) counter - traction with dilating sheath,3)4 ) femoral workstation,12 ) laser sheath,13 ) and electrosurgical sheath.14 ) traction and counter - traction using locking stylet and dilating sheath is a conventional technique for pacemaker and icd lead extraction . it has been proven to be effective and safe in clinical trials.3)4 ) although newly developed techniques such as electrosurgical or laser sheath are in clinical use , they have not been introduced in korea , and the conventional technique using locking stylet and dilator sheath is still useful if performed by experienced operators.14 ) the authors tried 25 pacemaker and one icd lead extractions associated with lead malfunction or infection since 2004 . of the 26 cases , 24 cases were successfully managed with the conventional traction and counter - traction technique using locking stylet and dilator sheath . in the two failed attempts , the operators could not advance the dilator sheath to the icd lead tip due to severe fibrous adhesion at the subclavian vein and in the superior vena cava . of the 24 successful cases , open heart surgery was performed in one case due to cardiac tamponade following complete pacemaker ventricular lead extraction . icd lead extraction is known to have higher complication rate than pacemaker lead extraction.6 ) however , it can be removed successfully with the same techniques . to our knowledge , this is the first icd lead extraction case reported in korea .