Intravascular lead extraction using locking stylets and sheaths

Feasibility, safety, and determinants of extraction time of percutaneous extraction of endocardial implantable cardioverter defibrillator leads by intravascular countertraction method

Previous studies of the removal of implantable cardioverter defibrillator (ICD) leads have been restricted to case reports or small series. In this report, we describe our experience in ICD lead extraction by intravascular countertraction method using Cook's extraction kit. A total of 47 high-voltage (HV) leads, 3 rate sensing (S) leads, and 2 subcutaneous arrays were removed from 42 patients (33 men, 9 women; mean age 59 years [range 14 to 81]). One HV superior vena cava (SVC) lead and 11 HV right ventricular (RV) leads were explanted by manual traction only and defined in the "lead removal" category. One S lead was removed using a femoral venous approach. The remaining 37 leads were explanted by SVC approach using extraction sheaths and defined in the "lead extraction" category. Twenty leads were extracted for "infectious" (group A) and 17 leads for "noninfectious" (group B) etiologies for which extraction times of 27.0+/-18.0 and 27.0+/-15.0 minutes (mean+/-SD), respectively, were not different. Although extraction time, 34.0+/-11.0 minutes, for leads implanted for >48 months was longer than 23.0+/-16.0, 28.0+/-18.0, and 24.0+/-14.0 minutes, for leads with implant durations of 12, 24, and 48 months, respectively, such differences were not statistically significant. The extraction time, however, was directly related to the degree of fibrosis around the lead, 39.0+/-15.0 minutes for leads with severe fibrosis compared with 13.0+/-6.0 minutes for the leads with mild fibrosis (p<0.001). Patient's age, sex, or history of coronary artery bypass graft surgery did not significantly affect extraction time. All except the initial 2 lead extractions were performed in the electrophysiology laboratory. No mortality or serious complications associated with the procedure using these methods were observed.

Current concepts in extraction of transvenous pacing and ICD leads

Extraction of chronically implanted pacing leads involves a thorough understanding of the pathophysiology of lead maturation and the problems that may occur. It also requires specific knowledge of lead construction and the idiosyncrasies of individual lead models. Though we have evolved to use a standardized approach to lead extraction, each patient and lead removal is unique. The operator must be ready to adapt the technique and tools used to the situation at hand. The more experience and the more tools available to the operator, the more likely that there will be a safe and successful outcome to the procedure. Preparation for disaster is mandatory, such that when a complication does occur, one may respond quickly and therefore salvage the patient.

Intravascular extraction of problematic or infected permanent pacemaker leads: 1994-1996. U.S. Extraction Database, MED Institute

Of the 400,000-500,000 permanent pacemaker leads implanted worldwide each year, around 10% may eventually fail or become infected, becoming potential candidates for removal. Intravascular techniques for removing problematic or infected leads evolved over a 5-year period (1989-1993). This article analyzes results from January 1994 through April 1996, a period during which techniques were fairly stable. Extraction of 3,540 leads from 2,338 patients was attempted at 226 centers. Indications were: infection (27%), nonfunctional or incompatible leads (25%), Accufix or Encore leads (46%), or other causes (2%). Patients were 64+/-17 years of age (range 5-96); 59% were men, 41% women. Leads were implanted 47+/-41 months (maximum 26 years), in the atrium (53%), ventricle (46%), or SVC (1%). Extraction was attempted via the implant vein using locking stylets and dilator sheaths, and/or transfemorally using snares, retrieval baskets, and sheaths. Complete removal was achieved for 93% of leads, partial for 5%, and 2% were not removed. Risk of incomplete or failed extraction increased with implant duration (P<0.0001), less experienced physicians (P<0.0001), ventricular leads (P<0.005), noninfected patients (P<0.0005), and younger patients (P<0.0001). Major complications were reported for 1.4% of patients (<1% at centers with >300 cases), minor for 1.7%. Risk of complications increased with number of leads removed (P<0.005) and with less experienced physicians (P<0.005); risk of major complications was higher for women (P<0.01). Given physician experience, appropriate precautions, and appropriate patient selection, contemporary lead removal techniques allow success with low complication rates.

Percutaneous extraction of an abandoned coiled pacing lead

Abandoning redundant pacing leads has been an accepted practice in most cases. Late migration of a lead is a rare, unpredictable, and potentially lethal complication of this approach and requires immediate removal. We report the case of an atrial pacing lead that had migrated and was found coiled in the right atrium. It was removed by a snare catheter via a femoral approach.

Excimer laser assisted extraction of permanent pacemaker and ICD leads: present experiences of a European multi-centre study

OBJECTIVE

Excimer Laser technique can be used to extract leads. We present the European multi-centre experience.

METHOD

The Spectranetics Excimer Laser is a Xenon-Chloride laser with a wavelength of 308 nm, not visible to the human eye. This cool cutting laser (50 degrees C) has an absorption depth of 0.06 mm. The laser energy is emitted from the tip of flexible 12, 14 or 16 French (Fr) probes and is absorbed by proteins and lipids. The fibrotic sheaths usually surrounding leads can be cut without damaging the endothelial wall or the insulation of other leads.

RESULTS

From August 1996 to August 1998, 179 leads (104 atrial, 57 ventricular, one SVC, 17 ICD) in 149 patients (mean age 68.3 years, range 14-94) were extracted in 11 centres. Mean implantation time was 68.3 months (2.8-357.8). Most common indications were patient morbidity, non-function, pocket infection, septicaemia or endocarditis. Median extraction time was 10 min (1-189). Most procedures (78%) were performed in operating rooms. Complete extraction was achieved in 89.5% of the leads, 6% were partially extracted and 4.5% of the extractions failed. In the majority of the partial cases, only minor lead parts without clinical significance were left. Of the failures, 3/8 were completely removed by femoral non-laser approach, 1/8 with a right subclavian approach and 1/8 with thoracotomy. Complications were few but included one ventricular perforation that did not need surgery; two other perforations were related to the reimplantation of leads and required surgery. Mean hospital stay was 3 days and all patients were discharged well and alive.

CONCLUSIONS

Excimer Laser assisted lead extraction is a safe and efficacious procedure. Open-chest extractions are still necessary but can be limited to very selected cases. These initial results may widen indications from mandatory to include the extraction of many non-functional leads, previously abandoned.

Pulmonary embolization of a pacing electrode fragment complicating lead extraction

We present a case that demonstrates an unusual complication of electrode extraction, namely asymptomatic embolization of a pacing electrode fragment into the pulmonary vascular bed.

Postmortem analysis of encapsulation around long-term ventricular endocardial pacing leads

OBJECTIVE

To analyze the site and thickness of encapsulation around ventricular endocardial pacing leads and the extent of tricuspid valve adhesion, from today's perspective, with implications for lead removal and sensor location.

MATERIAL AND METHODS

Gross cardiac postmortem analysis was performed in 11 cases (8 female and 3 male patients; mean age, 78+/-7 years). None of the patients had died because of pacemaker malfunction. The mean implant time was 61+/-60 months (range, 4 to 184).

RESULTS

The observations ranged from encapsulation only at the tip of the pacing lead to complete encapsulation along the entire length of the pacing lead within the right ventricle. Substantial areas of adhesion at the tricuspid valve apparatus were noted in 7 of the 11 cases (64%). The firmly attached leads could be removed only by dissection, and in some cases, removal was possible only by damaging the associated structures. No specific optimal site for sensor placement could be identified along the ventricular portion of the pacing leads; however, the fibrotic response was relatively less prominent in the atrial chamber.

CONCLUSION

Extensive encapsulation is present in most long-term pacemaker leads, which may complicate lead removal. The site and thickness of encapsulation seem to be highly variable. Tricuspid valve adhesion, which is usually underestimated, may be severe. In contrast to earlier reports, our study demonstrates that the extent of fibrotic encapsulation may not be related to the duration since lead implantation. Moreover, we noted no ideal encapsulation-free site for sensors on the ventricular portion of long-term pacing leads.

Extraction of pacemaker and implantable cardioverter defibrillator leads

The common reasons for removal of pacing and defibrillator leads are infection, malfunction, or design defects such as fracture of J wires in Teletronics Accufix leads (Telectronics Pacing, Englewood, CO), which impose considerable risk for cardiac morbidity and mortality. Chronically implanted leads are fixed to the myocardium by fibrous tissue. Fibrous scar tissue may also encase the lead along its course. Furthermore, fragility of the lead and its tendency to break when extraction force is applied to overcome resistance imparted by the scar tissue add to the challenge of lead extraction. Thus, the extraction of chronically implanted leads is an important issue. Until a few years ago, the only methods available for the removal of chronically implanted leads were traction on the proximal segment of the lead and cardiac surgery. New techniques were developed to extract the leads by a transvenous approach using locking stylets, sheaths, snares, and retrieval baskets. Lead extraction using intravascular countertraction methods has since evolved as a specialty of its own. Progress has also been made in developing other system, such as Excimer laser energy for lead extraction. In this article, we discuss principles, techniques, and experience with these methods of extraction of chronic pacemaker and defibrillator leads.

Stent dilation of superior vena cava and innominate vein obstructions permits transvenous pacing lead implantation

The purpose of this study was to assess the feasibility of stent dilation of venous obstructions/occlusions to permit transvenous pacing lead implantation. Innominate vein or superior vena cava (SVG) obstruction may preclude the implantation of transvenous pacing leads. Patients with d-transposition of the great arteries, after a Mustard or Senning procedure, and children with previously placed transvenous pacing leads are at higher risk for this vascular complication. From May 1993 to January 1996, eight pediatric patients who underwent transvenous pacing lead implantation or replacement were found to have significant innominate vein or SVC obstruction or occlusion. Utilizing intravascular stents, a combined interventional and electrophysiological approach was used to relieve the venous obstruction and to permit implantation of a new transvenous pacing lead. Two patients had complete SVC occlusion requiring puncture through the obstruction with a transseptal needle. Vessel recanalization was achieved with balloon dilation and stent implantation. The remaining six patients had severe venous obstruction with a mean minimum diameter of 3.1 +/- 3.3 mm. The mean pressure gradient across the obstructed veins was 8.6 +/- 7.3 mmHg. Following implantation of 15 Palmaz P308 stents in eight vessels, the mean diameter increased to 14.2 +/- 1.9 mm and the mean pressure gradient across the stented vessels decreased to 1.0 +/- 2.0 mmHg. A transvenous pacing lead was implanted successfully through the stent(s) immediately or 6-8 weeks later. Innominate vein and SVC obstruction can be safely and effectively relieved with intravascular stents and permit immediate or subsequent transvenous pacing lead implantation.

Successful percutaneous extraction of pacemaker leads with a novel (VascoExtor) pacing lead removal system

A new pacing lead extraction system (VascoExtor, VascoMed, Germany) with a universally applicable locking stylet was used over a period of 12 months to extract 25 permanent pacemaker leads (mean implantation time 3.9 +/- 3.8 years) in 16 patients who had pacemaker infection (n = 13), lead dysfunction (n = 2), or before an automatic defibrillator implant (n = 1). With use of this system, we were able to successfully and safely remove 24 of 25 chronic pacing leads (96%) in 15 of 16 patients (93%) with sole use of the locking stylet in 81%, and with use of an array of ancillary tools in the remaining 19% of patients.

First European experience using excimer laser for the extraction of permanent pacemaker leads

An Excimer Laser system for the extraction of permanent pacemaker leads has been developed by Spectranetics Inc. and Dr. Charles L. Byrd. The laser energy is emitted at the tip of a flexible, fiberoptic 12F sheath that permits the removal of leads with a max. outer diameter of 7.1F. The CVX-300 Excimer Laser source is a xenon chloride laser with an output of 308 nm not visible to the human eye. This cool cutting laser has an absorption depth of 0.06 mm, the energy being absorbed by proteins and lipids. In clinical practice this means that the fibrotic sheaths usually surrounding the leads can be cut without damaging the endothelial wall or the insulation of leads, due to these characteristics the sheath can, however, not pass over tines. For the freeing of lead tips, locking stylets and outer sheaths are combined to perform counter traction.

RESULTS

From 8/96 to 5/97 50 leads (38 atrial, 12 ventricular) from 45 patients (22 females, 23 males, mean age 65.1 years, range 32-94) were extracted using the Excimer Laser at our institution. Mean lead implantation time was 47.7 months (range 10.5-351.7). Indication for extraction was suspected J-wire fracture in 16 leads, prophylactic in 8 leads, infection in 12 leads, exit block in 4 leads and other reasons in 10 leads. Mean extraction time, excluding reimplantation, was 10 minutes (range 1-50). The objective of the procedure (normally complete lead removal) was accomplished in all cases but three. All intended lead replacements were successful. No complications occurred. All patients left the hospital in good condition, one patient died, within 30 days due to progressive heart failure.

CONCLUSIONS

Lead extraction with Excimer Laser seems to be a safe and efficacious procedure. However, due to the inherent risks appropriate training and experience are essential. If the initial promising results can be maintained, indications for the removal of permanent pacing leads may widen considerably.

Teletronics 330-801 atrial lead extraction via the subclavian approach

BACKGROUND

The Telectronics 330-801 atrial J (801) lead was recalled after reports implicated lead fracture/retention wire protrusion in patient mortality and morbidity. Recent reports suggest that 801 lead extraction may be associated with substantial morbidity and, possibly, excess mortality. We hypothesized that the 801 lead could be extracted using the subclavian approach with a high success rate and acceptable morbidity.

METHODS

We analyzed the clinical outcomes in 60 consecutive patients who underwent 801 lead extraction.

RESULTS

Sixty patients (34 women) with a mean age of 67 +/- 14.8 years had 18 class I, 13 class II, and 29 class III fractures. The lead age was 39 +/- 17 months. The subclavian approach was successful in 58 of 60 patients (96%). Complications, three major and eight minor, occurred in 10 of 60 patients (16%). All complications were successfully treated. There were no deaths. Only concurrent ventricular lead extraction was associated with complications (p = 0.008 by Fisher's exact test).

CONCLUSIONS

Telectronics 801 leads can be successfully extracted using the subclavian approach with acceptable short-term morbidity, low mortality, and excellent long-term results.

Unusual placement of a pacemaker pocket

Because of infection and extensive radiation injury to the skin of the chest wall, a dual chamber pacemaker was implanted deep to the clavicle. The wound has been stable and comfortable for 1 year and pacemaker programming has been unimpaired.

Extraction of permanent pacing leads: there are still controversies

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Lead extraction in young patients with and without congenital heart disease using the subclavian approach

Pacemaker lead removal using interlocking stylets and dilator sheaths has greatly reduced the need for major surgical intervention when lead extraction is required. Previous reports have shown the utility of this method in older patients, most of whom have anatomically normal hearts. The purpose of this study is to report the results of this technique in young patients with and without congenital heart disease. There were 13 patients (M:F = 7:6) aged 9-26 years (median 13). Congenital heart disease was present in 8 of 13 patients. A total of 17 leads required removal; they had been implanted for 54 +/- 24 months (range 19-94). Leads were removed from the left subclavian vein (13) or right subclavian vein (4) only. Seventeen of 18 leads were completely removed and one partially retained in the left subclavian vein. New leads were implanted from the same vein in 11 of 13 patients. Interlocking stylets and metal or flexible dilator sheaths were used in all cases except two. There was one surgical complication: a late wound dehiscence, which was easily managed. No patient required a transfusion, and there was no structural damage noted in any patient on the postoperative echocardiogram. We conclude that lead removal using interlocking stylets and dilator sheaths from the subclavian approach is an effective technique that can be used in young patients, including those with congenital heart disease.

Extraction of the Telectronics Accufix 330-801 atrial lead: the Mayo Clinic experience

OBJECTIVE

To document a cumulative experience with removal of the Telectronics 330-801 Accufix atrial lead after it was withdrawn from the market.

DESIGN

We reviewed our results with 96 attempted lead extraction procedures through Dec. 1, 1995.

MATERIAL AND METHODS

All patients underwent preoperative assessment, including fluoroscopic screening of the lead. Patients had blood typing and screening done before the extraction procedure, and extractions were performed with cardiac surgical intervention available. Pacing dependence was assessed to determine the need for temporary pacing.

RESULTS

The mean patient age was 65.7 +/- 1.6 years and the mean duration of lead implantation was 31.0 +/- 1.4 months. Of the 96 lead extractions attempted, 94 were successful. Of the 96 cases, the retention wires were normal in 29, fractured without protrusion in 34, and fractured with protrusion in 33. Fifty-three leads were removed with use of simple traction only, and seven leads were removed by using a locking stylet and telescoping sheaths. The Cook workstation was used in the removal of 32 leads through the femoral vein; in 1 of these 32 patients, the retention wire was removed before lead extraction. The retention wire was removed but the lead was left intact in one patient. One lead was removed during an opertive maze procedure. Associated complications were minimal.

CONCLUSION

Although lead extraction is a potentially fatal procedure, the Telectronics 330-801 Accufix atrial lead can be extracted safely with minimal morbidity when performed by experienced personnel.

Evaluation and extraction of the Accufix atrial J lead

The Accufix (Telectronics Pacing Systems, Englewood, Colo.) atrial active fixation pacemaker lead has a preformed J stiff retention wire that can fracture and erode through the atrium. We screened 85 patients with digital fluoroscopy and detected 18 (21%) lead fractures. Fourteen (16%) leads were successfully extracted by percutaneous techniques. The mean time for extraction and placement of a new atrial lead was 109 +/- 53 min, and a lead > 1 year old but not in the presence of a fracture was associated with a significantly longer extraction time. There were two extraction complications. One patient had a fever following the extraction, and one patient had a focal sensory deficit 1 week after the extraction probably caused by a paradoxical embolus. Standard percutaneous extraction tools can be used for successful and safe removal of a fractured Accufix lead.

Three-year experience with a stylet for lead extraction: a multicenter study

INTRODUCTION

The extraction of chronically implanted and infected pacemaker and defibrillator leads is an important issue. This article describes the experience gathered between 1990 and 1994 by seven European centers regarding a locking stylet that is uniformly applicable for a wide variety of internal pacing coil diameters. This interventional locking stylet for lead extraction has an outer diameter of 0.4 mm (0.016 inches). The stylet consists of a hollow shaft in which an inner traction wire is embedded. At the tip of the inner traction wire an anchoring mechanism, which can be opened by retraction, is applied. Removal attempts were made for 150 leads, 110 in ventricular and 40 in atrial positions.

RESULTS

Complete removal was possible in 122 cases (81%). Partial removal was possible in 18 cases (12%). Failure to remove the lead with the extraction stylet was experienced in 10 cases (7%). In seven patients, the leads were removed by cardiothoracic surgery; 3 defective leads were left in place. There were no serious complications associated with the procedure. None of the patients died.

CONCLUSION

The experience with this extraction stylet for lead removal has shown good results. Despite a low complication rate thus far, each case for lead removal should be judged on the individual basis of benefit-to-risk ratio.

Removal of infected dual chambered transvenous pacemaker and implantation of a new epicardial dual chambered device with cardiopulmonary bypass: experience with seven cases

Seven patients with infected transvenous dual chambered pacemakers have undergone removal of the device using cardiopulmonary bypass. There were four women and three men with a mean age of 58 years. Six patients had localized infection in the generator pocket (mean of 4.6 previous unsuccessful operations for surgical sterilization). Four infections were due to Staphylococcus epidermidis, two to Staphylococcus aureus, and one patient presented septicemia caused by Staphylococcus epidermidis and Pseudomonas aeruginosa. The atrial and ventricular transvenous electrodes were removed under direct vision using cardiopulmonary bypass. A new dual chambered epicardial pacemaker was implanted. The procedure was well-tolerated, and all patients are infection free with working pacemakers after a mean follow-up of 25.4 months.

Percutaneous removal of infected permanent pacemaker leads using a simple coaxial dilating system

A simple traction-countertraction technique using common and readily available materials was successfully used to remove infected pacemaker leads from two patients. The specific methodology is presented. Although somewhat technically demanding, this approach appears safe and cost-effective. This method provides another way to remove pacemaker leads without resorting to thoracotomy.

Five-years experience with intravascular lead extraction. U.S. Lead Extraction Database

From December 1988 to April 1994, the extraction of 2,195 intravascular pacing leads from 1,299 patients was attempted at 193 centers. Indications were: infection (54%, including 10% septicemia), pacemaker reoperation with removal of nonfunctional or incompatible leads (40%), and other causes (6%). Extraction was attempted via the implant vein using locking stylets and dilator sheaths, via the femoral vein using snares, retrieval baskets, and sheaths, or via both approaches. Leads had been implanted for 0.2 months to 24 years (mean 56 months). At the conclusion of the intravascular procedure, 86.8% of the leads were completely removed, 7.5% were partially removed, and 5.7% were not removed. For physicians performing their first case, 12% of leads were not removed; for physicians who had performed more than 10 cases, only 2% of leads were not removed. Of the 189 leads where extraction attempts had previously failed, 75.1% were completely removed, 14.8% were partially removed, and 10.1% were not removed. Scar tissue increased in severity with implant duration, was a complicating factor, and was the main cause of failure to remove leads. Use of the femoral approach increased with implant duration (5% of leads implanted 12 months or less, 11% of leads 13 months to 3 years, 20% of leads 4-7 years, and 31% of leads 8-24 years), primarily because of increasingly abundant scarring and prior lead damage. Fatal and near fatal complications occurred in 2.5%, including 8 (0.6%) deaths (3 hemopericardium/tamponade, 1 hemothorax, 3 pulmonary embolus, 1 stroke).(ABSTRACT TRUNCATED AT 250 WORDS)

Intravascular extraction of chronic pacemaker leads: efficacy and follow-up

Extraction of chronic pacemaker leads has been recommended for infections, prevention of venous thrombosis, migration, and possible perforation. Success with constant traction techniques has been variable, and the cost and morbidity of open chest surgical procedures are prohibitive. Efficacy of a new system for lead extraction using intravascular techniques was analyzed. The system (Cook Pacemaker) uses a locking stylet, which is secured at the distal electrode by counterclockwise rotation to reinforce the lead and facilitate traction, and dilator sheaths that are used to free the lead from adhesions in the venous system. In a series of 56 patients (ages 19-88) who presented for lead extraction because of erosion (5), infection (14), lead replacement (35), or other (2), 86 leads were extracted. Thirty-two were atrial leads and 54 ventricular; 23 had active fixation and 63 passive. Average duration of implant was 58 +/- 42 months (range 1-264). Eighty-four leads were totally removed and two partially removed. For these two leads, the distal tip was not removed; in both cases the locking stylet was not secured at the distal electrode due to obstruction within the lead. Two patients developed arm edema following the procedure, which resolved with elevation. One patient developed a subclavian thrombosis, which resolved with warfarin anticoagulation. Four patients have expired due to unrelated causes. In conclusion, this intravascular approach for extraction of chronic leads is effective, and the procedure is safe when performed by experienced personnel.

Myocardial Rupture After Pulling Out a Tined Atrial Electrode with Continuous Traction

Transvenous traction for the removal of retained pacemaker electrodes is common practice with few reported complications. This case reports a patient with a DDD pacemaker with extruded electrodes, who died of a myocardial rupture at the atrial lead site after prolonged (i.e., after 24 hours) traction was applied.

Successful percutaneous extraction of a chronic left ventricular pacing lead

This report describes a patient with a chronic endocardial left ventricular pacing lead. To avoid the risk of future embolization, it was felt that the lead should be removed and right ventricular pacing established. The lead was carefully evaluated by transesophageal echocardiography to exclude adherent thrombus. Successful percutaneous lead extraction was accomplished without sequelae, thus avoiding the morbidity of a thoracotomy.

Advances in pacing therapy for bradycardia

Advances have been made rapidly in the field of cardiac pacing. The most significant technologic advance is that of pacemakers capable of rate-adaptive pacing. Multiple types of sensors are now used for rate-adaptive pacing; some are commercially available and many are undergoing clinical investigation. In the near future, clinical investigation will begin on pacemakers that incorporate dual simultaneous sensors for rate-adaptive pacing. Significant improvement has been made in electrode design. Electrodes with low thresholds allow improved battery longevity. Steroid-eluting leads have proven reliable and capable of avoiding the early threshold rise seen with other electrodes. Standardization of pacemaker connector dimensions is now under way. The International Standards Organization has established the guidelines for connector standardization, and the guidelines have been adopted by the major manufacturers. The ultimate "smart" pacemaker would be capable of autoprogramming most or all of its programmable features. Many autoprogramming features have already been incorporated, and several others such as automatic programming of output and sensitivity are under investigation.