ClinicalDevicesTransvenous lead extraction in 1000 patients guided by intraprocedural risk stratification without surgical backup
Introduction
Transvenous lead extraction (TLE) has become an integral part of the long-term management of patients with cardiovascular implantable electronic devices (CIEDs). The TLE procedure is complex and carries a significant risk of life-threatening intraprocedural complications, namely, vascular laceration and cardiac avulsion, which typically require emergent surgical intervention.1, 2, 3 Several approaches to risk stratification have been proposed to identify patients at exceedingly high risk of procedural complications in whom backup surgery is necessary. However, while some schemes were shown to help identify a subset of patients whose extractions might be more difficult and complex, correlation with procedural outcome has been lacking. Therefore, TLE procedures have been considered a category of high-risk interventions, mandating the recruitment of vast resources, including the immediate availability of cardiothoracic surgical services.4,5
In this study, we describe a large series of consecutive patients undergoing TLE for noninfectious indications using an intraprocedural risk stratification approach to avoid catastrophic complications during TLE and reduce the need for surgical backup availability. This approach, by design, prefers lead extraction over lead abandonment whenever the extraction procedure could be performed safely without exposing the patient to unacceptably high-risk extraction techniques.
Section snippets
Study group
This is a single-center, single-operator, retrospective study of all consecutive patients who underwent elective TLE of a pacemaker or implantable cardioverter-defibrillator (ICD) lead at the Prairie Heart Institute between January 2008 and June 2020 without the availability of a backup surgical team. This approach of TLE was used in patients with noninfectious indications for extraction of atrial, ventricular, or coronary sinus pacemaker leads or single-coil ICD leads with a dwell time of <15
Demographic characteristics and indications for lead extraction
During the study period, 1000 patients were included in this analysis (52.7% female; mean age 61.5 ± 10.2 years; range 29–83 years). Demographic characteristics are listed in Table 1.
As shown in Table 2, a total of 1362 leads were extracted for an average of 1.4 leads per patient. The maximum number of leads extracted in a single patient was 4. The mean length of time since lead implantation was 73 ± 43 months (median 70 months; interquartile range 36–94 months). The most common indications for
Main findings
The main findings of this study are as follows: (1) laser/mechanical dissection at the SVC-RA junction was not necessary for successful extraction of the majority of leads in our selected study cohort; (2) the complication rates of TLE for noninfectious indications were extremely low when laser/mechanical dissection at the SVC-RA junction was avoided; (3) intraprocedural risk stratification during TLE can potentially reduce the need for the immediate availability of backup surgery; and (4) TLE
Conclusion
In the absence of reliable preprocedural risk predictors, identifying the small group of patients at exceedingly high risk of TLE procedural complications in whom the immediate availability of backup surgery is necessary remains challenging. In this study, the risk of TLE is judged intraprocedurally only after an attempt is made to extract the target lead as long as high-risk extraction techniques are avoided. This approach achieved successful TLE in the majority of patients, and none required
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Cited by (9)
Sex differences in outcomes of transvenous lead extraction: insights from National Readmission Database
2023, Journal of Interventional Cardiac ElectrophysiologyIn lead extraction, it's not where you go, but who you travel with
2023, Kardiologia Polska
Funding sources: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Disclosures: The authors have no conflicts of interest to disclose.