- As the implantation rate of cardiac implantable electronic devices has continued to increase, lead extractions for clinical indications such as infection, lead failure, and lead recall have also increased.1 A femoral approach to transvenous lead extractions is needed when removing previously cut and abandoned leads, leads that disrupt during a superior extraction attempt and in some cases involving central venous obstruction.2
- The first part of this review examined the infectious indications for lead extraction. This part discusses noninfectious indications for lead extraction and strategies for reducing the incidence of such indications.
- As the number of implanted devices continues to grow, so does the need for extraction of chronic endocardial leads. Extraction carries with it considerable risk of morbidity and mortality (both intraprocedure and postprocedure), even in experienced hands. Although the evolution of technology directed at this approach has facilitated the successful removal of leads, no evidence indicates that this technology has lessened the incidence or nature of adverse events. Risks associated with lead extraction include vascular and cardiac perforation, tricuspid valve injury, various arrhythmias, sepsis, pulmonary embolism, bleeding, stroke, and myocardial infarction.
- If manual extraction is not successful, a locking stylet is used after the inner lumen is reamed using another stylet to remove debris. Use of a locking stylet with a very flexible tip is essential so that a tortuous lead can be negotiated. Equally important is locking the stylet as close as possible to the lead tip and not allowing the stylet to slip during the procedure. The risk of severing the sometimes fragile interpolar section of encapsulated bipolar leads is high if a positive lock close to the lead tip cannot be achieved.
- The need for lead extraction has increased exponentially in the last decade due to greatly increased “total lead exposure time.” The increased total lead exposure time is the result of new indications for device treatment, device therapy involving more leads per patient, and longer average patient life. Improved general lead reliability noted over recent years may have decreased slightly the need for extraction; however, this effect is more than countered by recent advisories, recalls, and increased complication rates, probably related to many new centers offering device treatment.
- The incidence of device-related infections depends directly on the definition employed. The lack of precision is also compounded by the latency between the initiation and manifestation of the infection. It is not rare for there to be some erythema at the incision site during the first week of healing, and it is not clear that this represents infection. Less frequent, but still common, there can be a small, superficial stitch abscess, which will respond to local measures. When the diagnosis of device system infection is made, it should be made on the basis of pocket cellulitis, erosion, abscess, persistent bacteremia, or endocarditis with or without vegetation on the lead.
- Lead extraction has grown from a “niche” procedure practiced by a select few individuals to a fairly widely disseminated technique. With the apparent increase in device infections, occluded veins and the need for device “upgrades,” more physicians are attempting to extract chronically implanted pacing and implantable cardioverter-defibrillator (ICD) leads. Unfortunately, obtaining training for this procedure is difficult outside of a training program at a center with a physician experienced in lead extraction.
- The techniques and tools for percutaneous removal of transvenous leads have undergone substantial development over the past several decades. Although the use of locking stylets and powered sheaths to free leads from encapsulated scar tissue has improved the success rate, the procedure still carries a significant risk of morbidity and mortality even in the hands of experienced operators. The threshold for lead extraction continues to evolve. The initial use of the procedure was limited to patients with life-threatening infections because of limited tools, lower success rates and high complication rates.