Cardiac lead extraction with a novel locking stylet

Risk Factors Predicting Complications of Transvenous Lead Extraction

Objective

Transvenous lead extraction (TLE) is the gold standard in the management of patients with cardiac implantable electronic devices (CIED)-related complications. Knowledge of TLE risk factors is very important.

Methods

Clinical data from 1915 patients undergoing TLE at the Reference Center between 2006 and 2015 were analyzed. The effects of clinical and procedure-related factors on the development of major (MJC) and minor (MIC) complications and survival after TLE were evaluated.

Results

MJC were caused mainly by lead implant duration, presence of abandoned leads, multiple procedures preceding TLE, and any technical problem during TLE. Of clinical factors female gender and anemia increased the risk of MJC. MIC were reported in patients with the first implantation of CIED under the age of 30 and after sternotomy analysis of 30-day survival after procedure demonstrated a significant effect of clinical factors and lead dwell times, previous unsuccessful TLE, and MIC.

Conclusions

Efficacy and safety of TLE depend mainly on procedure-related factors. This knowledge is essential for preventing MJC and MIC. Mortality at 30 days following TLE is mainly associated with the clinical factors; however, there was also a significant effect of lead dwell time and periprocedural complications on the short-term prognosis of patients undergoing TLE.

Cardiac implantable electronic device lead extraction using the lead-locking device system: keeping it simple, safe, and inexpensive with mechanical tools and local anesthesia

Objective:

We have previously reported our successful approach for percutaneous cardiac implantable electronic device (CIED) lead extraction using inexpensive tools, which we have continued over the years. Herein we report the results of the systematic use of a unique stylet, the lead-locking device (LLD), which securely locks the entire lead lumen, aided with non-powered telescoping sheaths in 54 patients to extract 98 CIED leads.

Methods:

This prospective observational clinical study included 38 men and 16 women aged 68.9±13.1 years undergoing lead extraction for device infection (n=46), lead malfunction (n=5), or prior to defibrillator implant (n=3). Leads were in place for 6.7±4.3 years. Infections were more commonly due to Staphylococcus species (n=40). There were 78 pacing (31 ventricular, 37 atrial, 4 VDD, and 6 coronary sinus leads) and 20 defibrillating leads.

Results:

Using simple traction (6 leads) and the LLD stylets (92 leads) aided with telescoping sheaths (15 patients), 96 (98%) leads in 52 (96.3%) patients were successfully removed, with all but one leads removed using a subclavian approach; in 1 patient, the right femoral approach was also required. In 2 patients, distal fragments from one ventricular pacing and one defibrillating lead could not be removed. Finally, lead removal was completely (52/54) (96.3%) or partially (2/54) (3.7%) successful in 54 patients for 96 of 98 leads (98%) without major complications.

Conclusion:

Percutaneous lead extraction can be successful with mechanical tools using the LLD locking stylet aided with non-powered telescoping sheaths through a simplified, safe, and inexpensive procedure using local anesthesia alone.

Cardiac Implantable Electronic Device Infection in Patients at Risk

The incidence of infection following implantation of cardiac implantable electronic devices (CIEDs) is increasing at a faster rate than that of device implantation. Patients with a CIED infection usually require hospitalisation and complete device and lead removal. A significant proportion die from their infection. Transvenous lead extraction (TLE) is associated with rare but serious complications including major vascular injury or cardiac perforation. Operator experience and advances in lead extraction methods, including laser technology and rotational sheaths, have resulted in procedures having a low risk of complication and mortality. Strategies for preventing CIED infections include intravenous antibiotics and aseptic surgical techniques. An additional method to reduce CIED infection may be the use of antibacterial TYRX™ envelope. Data from non-randomised cohort studies have indicated that antibacterial envelope use can reduce the incidence of CIED infection by more than 80 % in high-risk patients and a randomised clinical trial is ongoing.

Lead extractions: indications, procedural aspects, and outcomes

As a result of more cardiac implantable electronic devices being placed, a trend toward increasing device infections, and concerns regarding lead malfunction, there is an increased need for lead extraction skills and comprehensive lead management programs. This review discusses the current indications for lead extractions as well as the training requirements and tools and technology needed to create the foundation for a successful lead management program.

Safety of transvenous lead extraction according to centre volume: a systematic review and meta-analysis

BACKGROUND

Transvenous lead extraction (TLE) is a complex invasive procedure and the experience of the operator and the team is a major determinant of procedural outcomes.

AIM

Because of very limited data available on minimum procedural volumes to enable training and ongoing competency for TLEs, we performed a meta-analysis aimed at assessing the outcomes of TLE in the centres with low, medium, and high volume of procedures.

METHODS

Of the 280 papers initially retrieved until February 2013, 66 observational studies met inclusion criteria and were included in at least one stratified meta-analysis: 17 were prospective studies; 47 had a retrospective design; and 2 were defined 'experience studies'. We included only articles published after the introduction of laser technique (year 1999). We divided the studies in low, medium, and high volume centres utilizing either the European Heart Rhythm Association (EHRA) or Lexicon classification criteria.

RESULTS

When meta-analyses were carried out separately for the studies with larger and smaller sample sizes, either using EHRA or Lexicon classification criteria, no clear differences emerged in the combined rate of major complications or intraoperative deaths. In contrast, both minor complications and mortality at 30 days decreased as centre volume increased.

CONCLUSIONS

In our meta-analysis of observational studies, patients who have been treated in higher volume centres have a lower probability of minor complications and death at 30 days regardless of the infection rate, length of lead duration, type of device, and type of extraction.

From lead management to implanted patient management: systematic review and meta-analysis of the last 15 years of experience in lead extraction

Percutaneous lead extraction is considered a safe and effective procedure, although published results derive primarily from cohort studies. The authors performed a systematic review and meta-analysis of the last 15 years' experience in this field, to give an objective evaluation of the efficacy and safety of this procedure. Moreover, the subsequent metaregression analysis enabled the identification of the main factors influencing these results: patient age, presence of leads in situ for more than 1 year, presence of device infection and use of laser sheath. These findings are significant in order to improve our extraction approach, data reporting and future research.

[ICD lead defects: diagnosis and therapeutical options]

The number of cardioverter/defibrillator (ICD) implantations has been steadily increasing; thus, ICD lead-associated complications are an important issue. No clear recommendations for the diagnosis and management are available. This article gives an overview of how to diagnose and manage an ICD lead defect. Possible therapeutic options are discussed by reviewing the literature.

Intracardiac echocardiography in patients with pacing and defibrillating leads: a feasibility study

BACKGROUND

Lead extraction, an important and necessary component of treatment for many common device and lead-related complications, is a procedure that can provoke much anxiety in even the most experienced operators given the potentially serious complications. The principal impediment to lead extraction is the body's response to an intravascular foreign body with matrix intravascular neoformation, which causes the lead to adhere to the endocardium or vascular structure, increasing the risk of vascular or myocardial damage with lead removal. Fluoroscopic visualization, the commonly visualization used tool, has several limits in terms of anatomical structures visualization. The aim of this study was to assess the safety and feasibility of intracardiac echocardiography (ICE) in patients undergoing pacing and defibrillating leads before and during a transvenous device removal, and its potential role in detecting intracardiac leads and areas of fibrous adherence.

METHODS

ICE interrogation was performed in 25 consecutive patients with pacing and defibrillating implantable cardioverter defibrillators (ICD) leads before and during device removal.

RESULTS

A programmed ICE analysis was completed in 23 out of 25 patients with excellent resolution, providing a "qualitative-quantitative" information on anatomical structures, cardiac leads, and related areas of fibrous adherence. No ICE-related complications occurred.

CONCLUSIONS

ICE evaluation is safe and feasible in patients with pacing and defibrillating leads before and during transvenous lead removal, offering an excellent visualization of cardiac leads and related areas of adherence. ICE can assist pacing and ICD lead removal and could improve procedure efficacy and safety.

Removal of embedded central venous catheters

BACKGROUND/PURPOSE

Long-term central venous access devices (CVAD) play an integral role in the management of children who require nutritional support, chemotherapy, blood drawing, and transfusion of blood products. Infrequently, the CVAD may be difficult or impossible to remove with traction.

PATIENT POPULATION

Four patients, with ages ranging from 6 to 13 years, had 4 CVAD in place for 431, 730, 2232, and 3285 days which could not be removed by manual traction and local exploration.

RESULTS

With the use of technology developed for removal of embedded transvenous pacemaker catheters, each CVAD was successfully dislodged using a lead locking device (n = 3) or a lead locking device and an excimer laser (n = 1). There were no complications of the procedure in our series.

CONCLUSIONS

There is no consensus on optimal management of embedded CVADs. In this small series, devices used routinely to remove embedded transvenous pacemaker wires were used to extract 4 embedded CVADs without complication; however, use of this technology in pediatric surgical patients is controversial because a small percentage of adult cases have resulted in tamponade or hemothorax, potentially resulting in death. Selection of patients and use of the technology in the appropriate setting are important considerations in weighing the risks vs the benefits of extracting such catheters or leaving them in place.

Transxyphoid Approach to Retrieval of Retained Pacemaker Leads Using Laser Sheath

The problem of retained intracardiac foreign bodies remains a concern, particularly in symptomatic patients with endocarditis. This report describes a recently applied technique using transxyphoid application of the Spectranetics Laser Sheath (SLS) for retrieval of a retained right atrial (RA) pacemaker lead. This approach represents modification of the Byrd's technique.

Pacemaker and defibrillator lead extraction

PURPOSE OF REVIEW

Continued growth in the elderly population and expanding indications have resulted in a progressive increase in the number of implants of pacemakers and defibrillators. Concomitant with these expanding numbers, more leads require removal, due especially to mechanical dysfunction, the need to upgrade to more complex devices, or local or systemic infection. Further, leads have become more complex, particularly for defibrillator systems, resulting in the development of powered extraction sheaths to expedite their removal. For these reasons, it is important to understand the expanding indications, procedural aspects, and limitations of arrhythmia device extraction.

RECENT FINDINGS

Expanded indications for lead extraction include upgrade to more complex systems, particularly pacemaker to defibrillator or biventricular device, extraction through occluded vasculature to produce a conduit for reimplantation, more frequent removal due to vascular overload with multiple leads, and a finite frequency of infection, occurring particularly with device replacement or revision. Powered sheaths now include laser and electrocautery systems, both improving the ease of lead explantation.

SUMMARY

Complication rates remain low but constant with extraction of larger numbers of leads using new technologies. Expansion of the use of biventricular systems, with implantation of coronary sinus electrodes, will continue to challenge lead extraction in terms of technology and safety. Design of leads that are easier to remove remains of paramount importance.