We appreciate the thoughtful comments from Dr. Ota and colleagues on our case report. First, we are sorry to have caused any misunderstanding about the message of our report. We never intended for our report to convey the message that it is always possible to manage superior vena cava (SVC) injury with conservative follow-up. We would like to warn that pseudoaneurysm formation of SVC can happen after lead extraction, even if the procedure itself was safely performed. Therefore, we believe that our case report is very appropriate from the standpoint of both humanitarian considerations and research ethics. Our report may be valuable for warning that unexpected and catastrophic “late” complications can happen if pseudoaneurysm of the SVC is not correctly diagnosed even after uncomplicated lead extraction.The discussion about the proper place for lead extraction in the operating room or catheterization laboratory is a little off topic because it is hard to detect pseudoaneurysm of the SVC during the procedure of lead extraction. In case 1, SVC pseudoaneurysm might be noted only with chest x-ray or CT after the procedure. We are still unclear that conservative management is always the best option for SVC pseudoaneurysm, but careful follow-up with imaging should be recommended. Reports of additional SVC pseudoaneurysms and proper management are warranted.No part of the current lead extraction guideline clearly states criteria about the proper place for lead extraction. One previous publication reported similar incidents of major complications and procedure-related mortality in the catheterization laboratory versus the operating room. Based on the report, we think it is too early to conclude that all lead extraction should be done only in the operating room. Because an increasing number of patients at our hospital required lead extraction, we developed institutional criteria for selecting hybrid operating room or catheter laboratory procedures according to the difficulty of the individual procedure and the patient’s condition, with agreement among the cardiologist, cardiac surgeons, and anesthesiologists to keep patients safe.Finally, readers may notice that Dr. Ota and colleagues are at our institution as well. Even in the same hospital with an institutional agreement for lead extraction criteria, there are different opinions. We assume that there are similar conflicts not only in our hospital but also in other hospitals. One reason could be that there are no specific guidelines about the best setting for lead extraction. Therefore, we hope that the Heart Rhythm Society or one of the other medical societies will launch specific criteria of the place for lead extraction.