Chronic transvenous pacemaker lead removal using a unique, sequential transvenous system

Strategies for Transvenous Lead Extraction Procedures

Transvenous lead extraction (TLE) has undergone an explosive evolution since its inception as a rudimentary skill with limited technology and therapeutic options. Early techniques involved simple manual traction that frequently proved ineffective for chronically implanted leads, and carried a significant risk of myocardial avulsion, tamponade, and death. The morbidity and mortality associated with these early extraction techniques limited their application to use only in life-threatening situations, such as infection and sepsis. The past four decades, however, have witnessed significant advances in lead extraction technology, resulting in more efficacious techniques and tools, providing the skilled extractor with a well-equipped armamentarium. With the development of the discipline, we have witnessed a growth in the community of TLE experts coincident with a marked decline in the incidence of procedure-related morbidity and mortality, with recent registries at high-volume centers reporting high success rates with exceedingly low complication rates. Future developments in lead extraction are likely to focus on new tools that will allow for us to provide comprehensive device management, develop alternative systems for extraction training, and focus on the design of new leads conceived to facilitate future extraction.

Lead Extraction Considerations for the Referring Cardiologist

The population of patients with cardiac implantable electronic devices (CIEDs) continues to grow due to increasing indications in an aging population and breakthroughs in both the medical and the surgical care of patients with heart disease. As a result, there has been a growing need for device and lead extractions due to the growing population of patients with CIEDs and the subsequent need for system upgrades or revisions because of complications, infections, and lead advisory alerts.

Extraction of cardiac rhythm devices: indications, techniques and outcomes for the removal of pacemaker and defibrillator leads

Cardiac rhythm management devices (pacemakers) are being increasingly implanted worldwide not only for symptomatic bradycardia, but also for the management of arrhythmia and heart failure. Their use in more elderly patients with significant comorbidities is rising steeply and consequently long-term complications are increasingly arising. Such an increase in device therapy is being paralleled by an increase in the requirement for system extraction. Safe lead extraction is central to the management of much of the complications related to pacemakers. The most common indication for lead extraction is system infection Adhesions in chronically implanted leads can become major obstacles to safe lead extraction and life-threatening bleeding and cardiac perforations may occur. Over the last 20 years, specific tools and techniques for transvenous lead extraction have been developed to assist in freeing the lead body from the adhesions. This article provides a comprehensive review of the indications, tools, techniques and outcomes for transvenous lead extraction. The success rate largely depends on the time from implant. Up to 12 months from implant, it is rare that traction alone will not suffice. For longer lead implant duration, no single technique is sufficient to address all extractions, but laser provides the best chance of extracting the entire lead. Operator experience is vital in determining success as familiarity of a wide array of techniques will increase the likelihood of uncomplicated extraction. Long implantation time, lack of operator experience, ICD lead type and female gender are risk factors for life-threatening complications. Lead extraction should therefore, ideally be performed in high volume centres with experienced staff and on-site support from a cardiothoracic surgical team able to deal with bleeding complications from cardiovascular perforation.

Is there an adverse outcome from abandoned pacing leads?

BACKGROUND

Indications for extraction of an abandoned pacemaker lead (APL) are controversial. The purpose of this study was to determine whether or not APLs should be extracted in the absence of pacemaker-related problems.

METHODS AND RESULTS

We retrospectively reviewed, from 1977 through 1998, all patients with retained, non-functional leads and identified 433-266 males and 167 females. Mean age at initial pacemaker implantation was 68[emsp4 ]years. These patients received a total of 259 atrial and 948 ventricular leads. Of the total of 1,207 leads, 611 became non-functional. A total of 531 non-functional leads were abandoned, of which 18 were later extracted: one APL in 345 patients, two in 78, and three in 10. Indications for new lead placement when non-functional leads were abandoned included capture and/or sensing failure (243), lead recall (177), lead fracture (86), pacing system replacement to the contralateral side (11), accommodating patient growth (5), pacemaker function upgrade (5), replacement with implantable cardioverter defibrillator (ICD, 2), interference with ICD (1), and unknown (1). Complications that were associated with pacemakers were found in 24 patients (5.5%)-pacemaker system infection (8 patients) and venous occlusion at the time of a subsequent procedure of new lead placement when APLs had already been in place (16) which resulted in APL extraction (7) or transfer of the pacemaker system to the contralateral side (9). Neither venous thrombosis nor other complications were found in the remaining 409 patients (94.5%). The incidence of complications was higher in patients with three APLs than in patients with two or fewer APLs (40% vs. 4.7%, P=1x10(-6)), in patients with four or more total lead implantations than in patients with three or fewer total lead implantations (26.2% vs. 0. 6%, P<1x10(-10)), and in patients with three or more procedures of new lead placements than in patients with two or fewer procedures of new lead placements (36.4% vs. 3.9%, P=1x10(-10)). Patients with complications were younger than those without complications both at the time of initial pacemaker implantation (59+/-16 vs. 68+/-17 y, P=0.01) and when non-functional leads were abandoned (63+/-15 vs. 71+/-16 y, P=0.04). Mean numbers of APLs, total leads implanted, and procedures of new lead placement were significantly larger in patients with complications than in those without complications (1.58+/-0.78 vs. 1.2+/-0.44, 4.96+/-1.23 vs. 2.66+/-0.8, and 2.13+/-0.85 vs. 1.25+/-0.53, P=0.03, 4x10(-9) and 4x10(-5), respectively).

CONCLUSIONS

1. With only 5.5% of patients having had pacemaker-related complications, the adverse outcome of APL is small. 2. Clinical clues to the possible occasion for pacemaker-related complications include three or more APLs, four or more total leads, three or more procedures of new lead placement, and a younger age at initial pacemaker implantation. 3. Patients with a large number of APLs, total lead implantations, and procedures of new lead placement should be carefully observed to detect possible pacemaker-associated complications.

Recommendations for extraction of chronically implanted transvenous pacing and defibrillator leads: indications, facilities, training. North American Society of Pacing and Electrophysiology Lead Extraction Conference Faculty

The procedure of lead removal has recently matured into a definable, teachable art with its own specific tools and techniques. It is now time to recognize and formalize the practice of lead removal according to the current methods of medicine and the health care industry. In addition, since at this time the only prospective scientific study of lead extraction is the PLEXES trial, we suggest that studies relating to the techniques of and indications for lead extraction be designed. Recommendations for a common set of definitions, for a framework of training and reviewing physicians in the art, for general methods of reimbursement, and for consistency among clinical trials have been made. Implementation of these recommendations will require additional effort and cooperation from practicing physicians, medical societies, hospital administrations, and industry.

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.

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.

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.

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.

[Removal of the endocardial pacemaker leads--experience with 16 leads in 10 patients]

Recent advances in pacemaker leads have contributed to the improvement of their stability at the anchored sites. However, we sometimes have difficulty in removing them. We have experienced the removal of 16 leads in 10 patients (male: 7, female: 3) in the last 5 years. The age of patients ranged from 48 to 87 years, and the average was 60. The reasons for the removal were as follows; pocket infection in 6 cases, sepsis in 1 case, ischemic skin erosion in 1 case, retained fractured ventricular lead in 1 case, fracture of Accufix atrial lead in 1 case. The methods of removal consisted of using the removal kit, the snare or the basket snare transvenously, direct surgical approach or a combination of them. We used the removal kit alone in 12 electrodes (6 atrial, 6 ventricular), and removal of 5 atrial and 3 ventricular leads were successfully by this method only. The removal of 4 leads by kits alone failed, so that 2 ventricular leads were removed transvenously, one atrial and one ventricular lead were removed surgically, and 1 ventricular lead was left untreated. Finally, we were able to remove 15 of 16 leads (93.3%) successfully. This experience indicates that these interventions should be performed as less invasively as possible, yet we should give an explanation to the patients as to the options we may employ when we have failed in the intended procedure.

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.

Surgical management of infected permanent transvenous pacemaker systems: ten year experience

BACKGROUND

Between January 1985 and June 1995, more than 1800 consecutive patients underwent implantation of a new permanent cardiac pacemaker at our institution. Thirty-six patients (0.02%) had 45 reinterventions for infected pacemaker systems.

METHODS

in group A, 24 of 27 patients received simultaneous implantation of a new pacemaker. One had reimplantation of the same pacemaker in the same pocket, and two did not require reimplantation. The leads were retained in 19 (70%) of the patients. In group B, nine patients underwent cardiopulmonary bypass or "pursestring" surgery for removal of an infected pacemaker; a new epicardial pacemaker system was simultaneously implanted in seven patients.

RESULTS

Identification of an infectious agent failed in 17 patients (47%), and Staphylococci were found in 15 patients (42%). The time from pacemaker implantation to onset of infection ranged from 1 month to 11 years (mean 31 months; median 19 months) and the time from onset of infection to surgical treatment from 1 month to 7 years (mean 7 months; median 2 months). The mean follow-up time is 74 months (range, 1 month to 10 years; median 5 years). There were 9 reoperations in 3 patients (16%) of group A for recurrent infection of their retained leads ultimately necessitating the use of open cardiac surgery. There was no early death; six patients died late due to unrelated causes.

CONCLUSIONS

Complete removal of all pacemaker leads is recommended; open heart surgery with the use of cardiopulmonary bypass is indicated in selected cases and is effective and safe.

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.

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)

The Dotter retriever and pigtail catheter: efficacy in extraction of chronic transvenous pacemaker leads

Several techniques exist for percutaneous extraction of chronic pacemaker leads. To establish the efficacy of the Dotter retriever and pigtail catheter, we reviewed the removal of 59 endocardial pacemaker leads in 42 patients (mean age 71 years). The mean duration of lead implantation was 44 months (range 1-169 months). Thirty-two leads were withdrawn with simple traction alone, and five leads were abandoned when traction failed. The remaining 22 leads were manipulated with a Dotter retriever or pigtail catheter, or both. Twelve leads were dislodged from the endocardium with simple traction (10) or with traction transmitted through an entwining pigtail catheter (2), but they could not be fully withdrawn. Eleven of these leads (92%) were then successfully extracted with the Dotter retriever. Seven of the remaining 10 leads were successfully dislodged and removed by the Dotter retriever. Overall, 9 of 12 leads (75%) that could not be dislodged from the endocardium with simple traction were removed with a Dotter retriever or pigtail catheter, or both. Three patients in whom no catheter method worked required thoracotomy for removal of infected leads. No complications resulted from use of the Dotter retriever or pigtail catheter. We conclude that the Dotter retriever and pigtail catheter have moderate efficacy for dislodging chronic endocardial leads. Once mobilized, however, the leads can be withdrawn with great success with the Dotter retriever. Newer technology should not result in the abandonment of this proven technique.

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.

Surgical removal of infected transvenous pacemaker leads

Infection, though uncommon, can be the most lethal of all potential complications following transvenous pacemaker implantation. Eradication of infection associated with pacemakers requires complete removal of all hardware, including inactive leads. Since 1972, 5,089 patients have had 8,508 pacemaker generators implanted at Montefiore Medical Center. There were 91 infections (1.06%); four of our patients required surgical removal. Nine additional patients were referred for surgical removal of infected transvenous pacemaker leads from other institutions. Surgical methods for removal included use of cardiopulmonary bypass or inflow occlusion. Surgery may be safely used in unstable or elderly patients and should not be reserved as a last resort. This article reviews our surgical experience removing infected pacemaker leads at Montefiore Medical Center.

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.