Procedural outcomes and long-term survival associated with lead extraction in patients with abandoned leads

When pacing or defibrillator leads become redundant: extract or abandon?

The 2017 HRS expert consensus paper on lead management and extraction did not express a preference for either extracting or abandoning pacing or defibrillator leads that are dysfunctional or superfluous after an upgrade (further referred to as redundant leads) 1. However, there are no randomized or even non-randomized trials that show a better patient outcome with extraction. Many experienced centers currently advise patients to have redundant leads removed to prevent more complicated procedures after years of abandonment. But according to the literature not all abandoned leads need to be extracted as more than 90% will have an uneventful follow-up. As immediate extraction of redundant leads has a small but significant risk this will generate more adverse events at population level than when extraction is limited to the patients with future lead complications, even considering a higher extraction risk at that time. Lead extraction is also limited to specialized centers and often necessitates expensive tools, in contrast to abandoning leads which can be safely performed by any experienced device specialist without additional cost.

Long-term outcomes with abandoning versus extracting sterile leads: A 10-year population-based study

BACKGROUND

Long-term outcomes of sterile lead management strategies of lead abandonment (LA) or transvenous lead extraction (TLE) remain unclear.

METHODS

We performed a retrospective study of a population residing in southeastern Minnesota with follow-up at the Mayo Clinic and its health systems. Patients who underwent LA or TLE of sterile leads from January 1, 2000, to January 1, 2011, and had follow-up for at least 10 years or until their death were included.

RESULTS

A total of 172 patients were included in the study with 153 patients who underwent LA and 19 who underwent TLE for sterile leads. Indications for subsequent lead extraction arose in 9.1% (n = 14) of patients with initial LA and 5.3% (n = 1) in patients with initial TLE, after an average of 7 years. Moreover, 28.6% of patients in the LA cohort who required subsequent extraction did not proceed with the extraction, and among those who proceeded, 60% had clinical success and 40% had a clinical failure. Subsequent device upgrades or revisions were performed in 18.3% of patients in the LA group and 31.6% in the TLE group, with no significant differences in procedural challenges (5.2% vs. 5.3%). There was no difference in 10-year survival probability among the LA group and the TLE group (p = .64).

CONCLUSION

An initial lead abandonment strategy was associated with more complicated subsequent extraction procedures compared to patients with an initial transvenous lead extraction strategy. However, there was no difference in 10-year survival probability between both lead management approaches.

Long-term outcomes of abandoned leads of cardiac implantable electronic devices

BACKGROUND

Evidence of the long-term outcomes of abandoned leads (ALs) in patients with cardiac implantable electronic devices (CIEDs) is scarce.

OBJECTIVE

This study aimed to investigate the long-term outcomes of ALs.

METHODS

This retrospective cohort study reviewed a single-center CIED registry of 2962 procedures performed from 1984-2018 and identified 130 patients with AL (AL group). We matched 2 controls without AL (by age, sex, device type, and device revision/removal date) to each patient with AL (n = 260) and compared CIED-related infection, venous thrombosis/stenosis, and all-cause mortality between groups using a Cox proportional hazard model analysis.

RESULTS

For a mean follow-up period of 11.2 ± 8.2 years, 14 (3.6%), 7 (1.8%), and 143 (36.7%) patients had a CIED-related infection, venous thrombosis/stenosis, or experienced all-cause mortality, respectively. The AL group had more comorbidities than the control group. Lead malfunction was the most common cause of abandonment (64.6%). After adjustment for covariates, no significant intergroup differences were noted in the risks of infection, venous thrombosis/stenosis, or all-cause mortality (adjusted hazard ratio [aHR] 2.52; 95% confidence interval [CI] 0.77-8.25; aHR 1.18; 95% CI 0.25-5.64; aHR 1.26; 95% CI 0.89-1.80, respectively). Patients with multiple ALs had increased risks of infection and all-cause mortality vs controls (aHR 8.61; 95% CI 2.13-34.84; aHR 2.42; 95% CI 1.17-5.00, respectively).

CONCLUSION

Patients with a single AL showed similar risks of CIED-related infections, venous thrombosis/stenosis, and all-cause mortality as those without ALs, whereas those with multiple ALs showed increased risks of infection and all-cause mortality.

Extraction of non-infected redundant pacing and defibrillator leads does not result in better patient outcomes

The introduction of dedicated tools for pacing and defibrillator lead extraction has resulted in relatively high success and low complication rates. The confidence this elicits has broadened the indications from device infections to non-functional or redundant leads and the latter make up an increasing share of extraction procedures. Proponents of extracting these leads point to the higher complication burden of lead extraction in patients with longstanding abandoned leads when compared one-to-one with extraction when these leads become redundant. However, this does not translate into better patient outcomes on a population level: complications are rare with properly abandoned leads and thus most patients will never be subjected to an extraction procedure and the ensuing complications. Therefore, not extracting redundant leads minimises the risk for the patients and avoids many expensive procedures.

Efficacy and Safety of Transvenous Lead Extraction at the Time of Upgrade from Pacemakers to Cardioverter-Defibrillators and Cardiac Resynchronization Therapy

BACKGROUND

Upgrading from pacemakers to ICDs and CRTs is a difficult procedure, and often, transvenous lead extraction (TLE) is necessary for venous access. TLE is considered riskier in patients with multiple diseases. We aimed to assess the complexity, risk, and outcome of TLE among CRT and ICD candidates.

METHODS

We analyzed clinical data from 2408 patients undergoing TLE between 2006 and 2021. There were 138 patients upgraded to CRT-D, 33 patients upgraded to CRT-P and 89 individuals upgraded to ICD versus 2148 patients undergoing TLE for other non-infectious indications.

RESULTS

The need for an upgrade was the leading indication for TLE in only 36-66% of patients. In 42.0-57.6% of patients, the upgrade procedure could be successfully done only after reestablishing access to the occluded vein. All leads were extracted in 68.1-76.4% of patients, functional leads were retained in 20.2-31.9%, non-functional leads were left in place in 0.0-1.1%, and non-functional superfluous leads were extracted in 3.6-8.4%. The long-term survival rate of patients in the CRT-upgrade group was lower (63.8%) than in the non-upgrade group (75.2%).

CONCLUSIONS

Upgrading a patient from an existing pacemaker to an ICD/CRT is feasible in 100% of cases, provided that TLE is performed for venous access. Major complications of TLE at the time of device upgrade are rare and, if present do not result in death.

Safety and efficacy of transvenous mechanical lead extraction in patients with abandoned leads

AIMS

Optimal management of redundant or malfunctioning leads is controversial. We aimed to assess safety and efficacy of mechanical transvenous lead extraction (TLE) in patients with abandoned leads.

METHODS AND RESULTS

Consecutive TLE procedures performed in our centre from January 2009 to December 2017 were considered. We evaluated the safety and efficacy of mechanical TLE in patients with abandoned (Group 1) compared to non-abandoned (Group 2) leads. We analysed 1210 consecutive patients that required transvenous removal of 2343 leads. Group 1 accounted for 250 patients (21%) with a total of 617 abandoned leads (26%). Group 2 comprised 960 patients (79%) with 1726 leads (74%). The total number of leads (3.0 vs. 2.0), dwelling time of the oldest lead (108.00 months vs. 60.00 months) and infectious indications for TLE were higher in Group 1. Clinical success was achieved in 1168 patients (96.5%) with a lower rate in Group 1 (90.4% vs. 98.1%; P < 0.001). Major complications occurred in only 9 patients (0.7%), without significant differences among the two groups. The presence of one or more abandoned leads [odds ratio (OR) 3.47; 95% confidence interval (CI) 1.07-11.19; P = 0.037] and dwelling time of the oldest lead (OR 1.01 for a month; 95% CI 1.01-1.02; P < 0.001) were associated with a higher risk of clinical failure.

CONCLUSION

Transvenous mechanical lead extraction is a safe procedure also in high-risk settings, as patients with abandoned leads. Success rate resulted a bit lower, especially in the presence of abandoned leads with long implantation time.

Transvenous lead extraction in 1000 patients guided by intraprocedural risk stratification without surgical backup

BACKGROUND

Transvenous lead extraction (TLE) carries a significant risk of morbidity and mortality. Reliable preprocedural risk predictors to guide resource allocation and optimize procedural safety are lacking.

OBJECTIVE

The aim of this study was to evaluate an intraprocedural approach to risk stratification during elective TLE procedures.

METHODS

This is a single-center retrospective study of consecutive patients who underwent elective TLE of a pacemaker or implantable cardioverter-defibrillator lead for noninfectious indications. 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. TLE was performed in a well-equipped electrophysiology laboratory with rescue strategies in place but in the absence of surgical staff.

RESULTS

During the study period, 1000 patients were included in this analysis (527 female (52.7%); mean age 61.5 ± 10.2 years). TLE was attempted for 1362 leads, with a mean lead dwell time of 73 ± 43 months (median 70 months; interquartile range 12-180 months). TLE was successful in 914 patients, partially successful in 10, and failed in 76 patients. A laser sheath was required for extraction of 926 leads (68%). Only 1 patient developed intraprocedural cardiac tamponade requiring emergency pericardiocentesis. None of the patients developed hemothorax or required surgical intervention.

CONCLUSION

At experienced centers, intraprocedural risk stratification for TLE that avoids high-risk extraction techniques achieved successful TLE in the majority of patients and can potentially help optimize the balance between efficacy, safety, and efficiency in lead extraction.

Lead extraction for cardiac implantable electronic device infection: comparable complication rates with or without abandoned leads

AIMS

Abandoned leads are often linked to complications during lead extraction, prompting pre-emptive extraction if leads become non-functional. We examined their influence on complications when extracted for device-related infection.

METHODS AND RESULTS

All patients undergoing lead extraction for device-related infection from 2006 to 2017 in our hospital were included. The primary endpoint was major complications. Out of 500 patients, 141 had abandoned leads, of whom 75% had only one abandoned lead. Median cumulative implant times were 24.2 (interquartile range 15.6-38.2) and 11.6 (5.6-17.4), respectively years with or without abandoned leads. All leads were extracted only with a femoral approach in 50.4% of patients. Mechanical rotational tools were introduced in 2014 and used in 22.2% of cases and replacing laser sheaths that were used in 5% of patients. Major complications occurred in 0.7% of patients with abandoned leads compared with 1.7% of patients with only active leads (P = 0.679). Failure to completely remove all leads was 14.9% and 6.4%, respectively with or without abandoned leads (P = 0.003), and clinical failure was 6.4% and 2.2% (P = 0.028), respectively. Procedural failure dropped to 9.2% and 5.7% (P = 0.37), respectively after the introduction of mechanical rotational tools. The only independent predictor of procedural and clinical failure in multivariate analysis was the cumulative implant duration.

CONCLUSION

Despite longer implant times, patients with abandoned leads did not have more major complications during lead extraction. Therefore, preventive extraction of non-functional leads to avoid complications at a later stage is not warranted.

Femoral extraction of transvenous leads and leadless pacemakers-A review of the data, tools, and procedural steps

Extraction of transvenous leads via the femoral route might be needed when extraction via the implant vein fails or when retained lead fragments exist. The skill set required for this procedure is unique as it relies on the ability to snare and the use of a variety of shelf tools. In this era of leadless pacing, this skill set might be called upon more frequently. In this article, we review the data, tools, and procedural steps of femoral lead extraction and retrieval/extraction of leadless pacemakers.