Lead extraction
Lead extraction is considered relatively high risk
​
Higher rates of complications are associated with
• Institutional procedural volume (If a physician does <80 procedures per annum, risk of complication triples)
•time from implant
•New leads (<6-12 months) can generally be removed quite easily
•Chronic leads will have a higher degree of fibrosis formed around the lead and be more difficult to extract
•Females
•Presence of infection
•Body mass index (BMI <25)
​
Major areas of fibrotic tissue often include
•SVC
•tricuspid valve
•myocardium
​
Where fibrotic tissue is present, the following can affect the difficulty of lead extraction
•strength of adhesion (fibrous tissue) and the forced required it break it
•tensile strength of the lead body
•tensile strength of the vessel or cardiac wall
​
Class I Indications for device/lead extraction
•Definite infection evidenced by valvular endocarditis, lead endocarditis, or sepsis
•Pocket infection evidenced by pocket abscess, device erosion, skin adherence, chronic draining sinus
•Leads causing life threatening arrhythmias.
•Failed lead due to poor designs that may be harmful to keep in –telectronics ACCUFIX J wire-fracture with protrusion)
•Leads that interfere with the operation of the device
•Leads that interfere with malignancy (radiation, reconstructive surgery)
​
Major complications
•Death
•Cardiac/vascular avulsion or tear requiring thoracotomy, pericardiocentisis, chest tube or surgical repair
•Pulmonary embolism requiring surgery
•Respiratory arrest or anaesthesia related complication leading to prolongation of hospitalisation
•Stroke
•Pacing system related infection of a previously non infected site-new infection
​
Minor Complications
•Pericardial effusion not requiring pericardiocentisis
•Hemothorax not requiring a chest tube
•Hematoma at the surgical sire requiring reoperation for drainage
•Arm swelling or thrombosis of implant veins resulting in medical intervention
•Vascular repair near the implant site or venous entry site
•Hemodynamically significant air embolism
•Migrated lead fragment without sequelae
•Blood transfusion due to blood loss during surgery
•Pneumothorax requiring a chest tube
•Pulmonary embolism not requiring surgical intervention
​
Techniques
•Gentle traction
•Stylet inserted down lead for support
•Locking stylet may be used to help transmit traction force
•Non powered sheaths
•Powered sheaths (laser): tips cut through fibrous tissue
​
Outcomes of lead extraction can be categorised into the following
•Complete procedural success (all targeted lead removed with absence of any disabling complication)
•Clinical success (removal of all targeted leads and lead material, with retention of small portions of lead where there is no negative effects. This does not apply to infected leads)
•Failure (inability to achieve complete or clinic success, or the development of a disabling complication/death
