Transvenous Pacemaker/ICD Lead Extraction
June 1, 2008 5 minutes read
Transvenous Pacemaker/ICD Lead Extraction
Abstract & Commentary
By John P. DiMarco, MD, PhD
Source: Jones SO 4th, et al. Large, single-center, single-operator experience with transvenous lead extraction: outcomes and changing indications. Heart Rhythm. 2008;5: 520-525.
In this paper, jones and colleagues from the Brigham and Women's Hospital in Boston report a seven-year experience with transvenous extraction of pacemakers and ICD leads. They performed a retrospective analysis of all consecutive patients undergoing chronic lead extraction by a single operator at their institution. Extractions of leads implanted fewer than six months prior were excluded from the analysis. They analyzed the indications for lead extraction, complications with the approach, and technical success rates.
Between January 2000 and March 2007, Jones et al removed 975 chronic endovascular leads from 498 patients. The mean implant duration was 7.5 ± 5.8 years, with one lead in place for 32.7 years. The removed device was a pacemaker in 53.2% of the patients and an ICD in 46.8% of the patients. The most common indication for lead extraction was infection. This was a localized pocket infection in 127 patients, skin erosion without obvious infection in 89 patients, and systemic infection and/or endocarditis in 85 patients. Lead malfunction was the indication for 146 patients. In 44 patients, the device was upgraded to a more complex system and an original lead extracted. Seven patients had leads extracted for other reasons.
Jones et al found that wound cultures were positive in 64.1% of those with infections with coagulase-negative staphylococcus, Staphylococcus aureus, Propionibacterium acnes, Candida species, and Corynebacterium, the most common organisms identified. Systemic infections were usually associated with Staphylococcus aureus or Enterococcus faecalis, group B streptococcus, or Candida.
The technique used by the investigators included exposure of the lead and the removal of any tie-down sutures, followed by attempts at manual extraction alone or manual extraction using a lead locking device. If this was unsuccessful, they went on to use an excimer laser sheath to disrupt binding sites in the circulation. Manual extraction alone was effective for only 22.4% of the chronically-implanted leads and a laser extraction technique was required in 77.6%. Absence of infection, longer lead duration, and younger patient age were predictors of the need for the laser extraction system, but it must be remembered that the large majority of all leads in this series required laser extraction.
The success rate for the extraction procedure was high. All portions of the lead were removed in 97.5% of the leads. In 18 patients, distal electrode fragments were retained in the heart, but these had no clinical significance. A femoral approach which allowed snaring of the lead, however, was required in 5.6% of patients.
Complications were quite rare. There were no procedure-related deaths or deaths during the index hospitalization. Two cases of cardiac tamponade occurred. These were treated with either pericardiocentesis or a thoracotomy. There were two cases of vascular thrombosis and one case of distal electrode embolization, which resolved without clinical sequelae.
Jones et al conclude that transvenous lead extraction can be performed with a high success rate and a low rate of major complications by an experienced operator in an appropriate setting. Success rates were higher and complication rate lower in this series than in prior reports.
Commentary
There has been an exponential growth in the number of patients who have pacemakers and implantable defibrillators that use transvenous leads. Unfortunately, infection rates associated with these devices, although low in experienced centers, remain a problem, and late lead deterioration with malfunction continues to occur. As the treatment of heart failure and arrhythmias improves over time, patients with these pacemakers, ICDs, and CRT devices are living longer. We can expect that more and more patients will need to have leads replaced or removed in the future.
Lead extraction is not particularly controversial in the setting on an infected device. Most authors consider it mandatory to remove all infected leads and devices when there are signs of systemic infection. When only a local pocket infection or erosion is present, lead extraction still usually provides the best chance for a successful outcome. There are situations where lead extraction is optional. Frequently, if a lead malfunctions or an additional atrial or defibrillation lead is to be added as part of an upgrade, the original venous access site is, or may become, totally or partially occluded. Here, removal of the original lead may help create a conduit. Finally, particularly in patients with multiple implants, removing nonfunctional leads may prevent venous occlusions and local problems by debulking the number of leads in the vein and the pocket. I find this particularly important in younger patients who are likely to have multiple lead failures over many years of therapy.
The efficacy and safety results from this single-center experience are quite impressive. There are, however, a number of factors that an operator has to consider when planning a lead extraction that are not dealt with here. The type of lead that is to be extracted may be important. Active fixation leads, in general, are easier to remove, particularly if they have a retractable fixation device. Dual coil ICD leads, particularly some of the older leads which did not have a uniform diameter are more difficult. Right sided leads are harder to remove than left-sided leads using only a superior approach because of the angles involved. Extractions in which multiple leads, particularly more than two, are involved, are often quite difficult because the leads interact with each other. A pre-procedure chest x-ray may show the leads wrapped around each other, but this is not always apparent until the actual extraction attempt. Although not seen in this series, in other series, female gender and body weight have been predictors of serious complications, presumably because the thickness of the tissue in the vasculature and in the heart encasing the lead to be removed may be decreased.
Lead extraction remains a challenging problem and one that should be reserved for experienced high volume operators. Decisions about lead extractions need to be made on a case by case basis. However, with improved technology for lead extractions and a thorough consideration of all of the clinical factors involved, most infected and non-functional leads can be successfully removed.
In this paper, jones and colleagues from the Brigham and Women's Hospital in Boston report a seven-year experience with transvenous extraction of pacemakers and ICD leads.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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