Lead Extraction - Indications, Techniques, and Complications

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Abstract

Management of pacemaker and implantable cardioverter–defibrillator (ICD) lead complications and the prevention of these occurrences continues to become more important as the number of implanted devices continues to rise. For many situations, especially device infections, removal of the leads is a critical part of managing the patient and obtaining a cure. What is becoming more apparent is that forward thinking in terms of removal of superfluous leads may allow easier and safer removal when performed earlier. The preparation of the patient, procedure, indications, and hospital requirements for the performance of lead extraction are discussed in this article.

Disclosure
Charles J Love, MD, FACC, FAHA, FHRS, CCDS, is a consultant and/or researcher for Biotronik, Boston Scientific, Cook Medical, Deringer-Ney, Medtronic, Spectranetics, St Jude Medical, TyRx, and WL Gore.
Correspondence
Charles J Love, MD, FACC, FAHA, FHRS, CCDS, 473 West 12th Avenue, 2nd Floor DHLRI, Columbus, OH 43210. E: Charles.Love@osumc.edu
Received date
15 June 2010
Accepted date
15 July 2010
Citation
US Cardiology - Volume 7 Issue 2,2010;37-41

Pages

Lead extraction is now being recognized as but one lead management strategy. Lead management is a higher level of thinking in terms of how to manage patients with cardiac implantable electronic devices (CIEDs) that utilize wires (leads) to sense, pace, and/or defibrillate the heart. Although new leadless systems are beginning to appear, they are still in the investigational stage. Nonetheless, millions of patients remain with devices that utilize standard lead systems. On occasion, a lead may need to be removed for any one of a number of reasons, as will be discussed below. When that time comes, the techniques that have been developed over the past 25 years come into play.1–8
One must first define the terms that will be used when discussing this topic.9 Lead removal is the process of taking out a lead by any technique. Lead explant is a term used for removal of a lead by simple traction utilizing only the tools typically used to implant the lead (e.g. standard stylet, helix extension/retraction tool, etc.). Lead extraction is used to describe the removal of a lead that has been implanted for more than a year, when specialized extraction tools are required (regardless of implant duration), or when an approach other than that used to implant the lead is required.
The second set of terms that must be defined relate to the outcome of the procedure.9 The most important result of lead removal is clinical success. This refers to the achievement of the goal of the procedure without causing a major complication. The goal may be to place a new lead through an occluded vessel, resolution of an infection, removal of superfluous leads, resolution of pocket-related symptoms (such as pain), or elimination of a lead or portion of a lead that poses a risk of arrhythmia, perforation, or other hazard. It is possible to achieve clinical success without removing 100% of the targeted lead or leads. However, a procedural success is the removal of all targeted leads and lead materials from the vascular space without a significant complication.
Prior to performing a lead-extraction procedure, the operator and the team that will be assisting the operator must have sufficient experience and training to allow the procedure to occur successfully and safely.9,10 The primary operator should be trained by having direct experience in the procedure. This involves hands-on experience of at least 40 lead extractions as a primary operator. Exposure to multiple lead types utilizing different extraction tools and approaches is necessary.

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