Preprocedural ECG-Gated Computed Tomography for Prevention of Complications during Lead Extraction

CAR and CSTR Cardiac Computed Tomography (CT) Practice Guidelines: Part 2-Non-Coronary Imaging

The cardiac computed tomography (CT) practice guidelines provide an updated review of the technological improvements since the publication of the first Canadian Association of Radiologists (CAR) cardiac CT practice guidelines in 2009. An overview of the current evidence supporting the use of cardiac CT in the most common clinical scenarios, standards of practice to optimize patient preparation and safety as well as image quality are described. Coronary CT angiography (CCTA) is the focus of Part I. In Part II, an overview of cardiac CT for non-coronary indications that include valvular and pericardial imaging, tumour and mass evaluation, pulmonary vein imaging, and imaging of congenital heart disease for diagnosis and treatment monitoring are discussed. The guidelines are intended to be relevant for community hospitals and large academic centres with established cardiac CT imaging programs.

Computed tomography predictors of increased transvenous lead extraction difficulty

BACKGROUND

The ability of computed tomography (CT) characteristics to predict the difficulty of transvenous lead extraction (TLE) is an evolving subject.

OBJECTIVE

To identify CT characteristics associated with increased TLE difficulty.

METHODS

All consecutive patients undergoing TLE at the University of California San Diego from January 2018 to February 2022 were analyzed, utilizing the UC San Diego Lead Extraction Registry. Patients underwent cardiac-gated chest CT scans with intravenous contrast; all scans were reviewed by a single radiologist. Lead extraction was performed per standard institutional protocol with the initial use of a laser sheath and crossover to a mechanical sheath as needed. Multivariable linear and logistic regression analyses were performed to identify predictors of individual lead-removal fluoroscopy time and mechanical sheath use, as markers of extraction difficulty.

RESULTS

A total of 343 patients were analyzed. The mean age of the study population was 63.8 ± 15.4 years; 71% were male. The mean lead dwell-in duration was 8.6 ± 5.7 years. In multivariable linear regression analysis, venous occlusion detected on CT was independently associated with higher individual lead-removal fluoroscopy time (p = 0.004), when adjusting for clinical characteristics such as lead dwell time. In multivariable logistic regression analysis, calcification and venous occlusion were independently associated with a higher need for mechanical sheath use during TLE (odds ratio:5.08, p < 0.001, 95% CI: 2.54-10.46) and (odds ratio:3.72, p < 0.001, 95% CI: 1.89-7.35), respectively.

CONCLUSION

In patients undergoing TLE, venous occlusion identified by chest CT is associated with increased fluoroscopy time. Patients with lead-associated calcification or venous occlusion detected by chest CT are each five and three times more likely to require crossover from laser to a mechanical sheath.

Open Chest Approach Lead Extraction in a Patient with a Large Vegetation: The Importance of Multidisciplinary Approach, Advanced Imaging, and Procedural Planning

We present a complex case of cardiac implantable electronic device infection and extraction in the setting of bacteremia, large lead vegetation, and patent foramen ovale. Following a comprehensive preprocedural workup including transesophageal echocardiogram and computed tomography lead extraction protocol, in addition to the involvement of multiple subspecialties, an open chest approach to extraction was deemed a safer option for eradication of the patient's infection. Despite percutaneous techniques having evolved as the preferred extraction method during the last few decades, this case demonstrates the importance of a thorough evaluation at an experienced center to determine the need for open chest extraction.

Infections of cardiac implantable electronic devices and how to improve transvenous lead extraction by the virtual reality

Introduction

Infections in cardiac implantable electronic devices (CIED) are increasing over time and associated with substantially mortality and healthcare costs. The best approach is the complete removal of the system by transvenous lead extraction (TLE). However, when leads are more than 10 years old, this technique requires considerable expertise and failures with the result of abandoned leads or serious complications may occur. The aim of this study is to describe our experience using virtual and mixed reality in the preoperative planning of complex cases.

Patients and methods

Consecutive patients from a referral centre with CIED infections in which TLE was judged difficult. Synchronized computed tomography (CT) scan images were processed and transferred to a fully immersive virtual reality room and also to the operative room (mixed reality) for better guidance during the extracting procedure.

Results

Ten patients (seven with local and three with systemic infections) were preoperative evaluated. Processed images and virtual reality showed intense adherences of the leads to the veins, right ventricle, and right atrium endocardium and between them that preclude a difficult extraction and required a carefully planning and sometimes a different technical approach. The anticipated difficulty was confirmed by the higher times of fluoroscopy. All leads were extracted and no complications were registered.

Conclusions

Preoperative planning is essential for evaluation of TLE difficulty and prevention of unexpected situations. Virtual reality seems an estimable aid for operators in planning difficult cases and also an excellent tool for teaching.

Supplementary information

The online version contains supplementary material available at 10.1007/s12055-023-01663-9.

Lead Extraction-Indications, Procedure, and Future Directions

Cardiac implantable electronic device (CIED) implantation has steadily increased in the United States owing to increased life expectancy, better access to health care, and the adoption of updated guidelines. Transvenous lead extraction (TLE) is an invasive technique for the removal of CIED devices, and the most common indications include device infections, lead failures, and venous occlusion. Although in-hospital and procedure-related deaths for patients undergoing TLE are low, the long-term mortality remains high with 10-year survival reported close to 50% after TLE. This is likely demonstrative of the increased burden of comorbidities with aging. There are guidelines provided by various professional societies, including the Heart Rhythm Society, regarding indications for lead extraction and management of these patients. In this paper, we will review the indications for CIED extraction, procedural considerations, and management of these patients based upon the latest guidelines.

Radiographic predictors of failure of simple manual traction of transvenous implantable cardioverter-defibrillator leads: a single-center experience

BACKGROUND

Extraction of the implantable cardioverter-defibrillator (ICD) leads could be a difficult procedure due to fibrous tissue around the lead and anatomical variations. In this report, we present our experience in the radiographic predictors of failure of simple manual traction (SMT) in patients with dual-coil ICD requiring lead extraction (LE).

METHODS

Between January 2017 and February 2021, 103 leads were removed in 65 consecutive patients; 65 (63.1%) were dual-coil ICD leads, 22 (21.4%) were atrial, and 16 (15.5%) were coronary sinus leads. Patient-based and procedural data were collected and analyzed retrospectively. Clinical and procedural characteristics were compared and radiographic predictors of failure of SMT of ICD leads were assessed. Projected anteroposterior (AP) lead tortuosity was measured and lead slack score was estimated on chest X-ray (CXR).

RESULTS

Simple manual traction failed in 27 (42%) of the ICD leads. Ottawa slack score (odds ratio [OR] 2.368, 95% CI [1.261-4.447]; P = 0.007), AP lead tortuosity > 1.10 (OR 7.477, 95% CI [1.718-35.542]; P = 0.007), and number of previous interventions (OR 6.016, 95% CI [1.184-30.557]; P < 0.030) were found to be independently related to the failure of SMT. Receiver-operator characteristic curve analysis yielded an AP lead tortuosity cutoff value of > 1.10 for predicting the failure of SMT. The area under the curve was 0.744; the 95% confidence interval (CI) was 0.617 to 0.871 (P = 0.001), with a sensitivity of 63% and a specificity of 73%.

CONCLUSION

Simple manual traction success in our study varied based on radiographic lead-related parameters. Before planning the procedure, increased AP lead tortuosity in vasculature and higher lead slack score can be easily determined on CXR and may be associated with more fibrous adherences, the complexity of the LE, and failure of SMT.

Prospective Evaluation of the Correlation Between Gated Cardiac Computed Tomography Detected Vascular Fibrosis and Ease of Transvenous Lead Extraction

BACKGROUND

Difficulty of lead extraction does not track well with procedural complications, but several small retrospective studies have lead fibrosis on computed tomography as an important indicator of difficult lead extraction. The purpose of the present study was to apply a standardized gated cardiac computed tomography (CT) protocol to assess fibrosis and study it prospectively to examine the need for powered sheaths and risk outcomes.

METHODS

We performed a prospective, blinded, multicenter, international study at high-volume lead extraction centers and included patients referred for transvenous lead extraction with at least one lead with a dwell time >1 year and ability to receive a cardiac CT. The degree of fibrosis (as measured by amount of lead adherence to vessel wall) was graded on a scale of 1 to 4 by dedicated CT readers in 3 zones (vein entry to superior vena cava, superior vena cava, and right atrium to lead tip). The primary outcome of the study was number of extractions requiring powered sheaths at zone 2 for each fibrosis group.

RESULTS

A total of 200 patients were enrolled in the trial with 196 completing full gated CT and lead extraction analysis. The primary endpoint of powered sheath (laser and mechanical) sheath use was significantly higher in patients with higher fibrosis seen on CT (scores 3+4; 67.8%) at the zone 2 compared to patients with lower fibrosis (scores 1+2; 38.6%; P<0.001). There were 5 major complications with 3 vascular lacerations all occurring in zone 2 in the study.

CONCLUSIONS

Gated, contrasted CT can predict the need for powered sheaths by identification of fibrosis but did not identify an absolute low-risk cohort who would not need powered sheaths.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT03772704.

Looking for Lead Adhesions While Planning for Transvenous Lead Extraction

The first implantable pacemaker was placed in the 1958, ushering in a new frontier of cardiovascular medicine. This article is protected by copyright. All rights reserved.

The Role of Preoperative Venography in Predicting the Difficulty of a Transvenous Lead Extraction Procedure

INTRODUCTION

We hypothesized that an accurate assessment of preoperative venography could be useful in predicting transvenous lead extraction (TLE) difficulty.

METHODS AND RESULTS

A dedicated preoperative venogram was performed in consecutive patients with cardiac implantable electronic device who underwent TLE. The level of stenosis was classified as without significant stenosis, moderate, severe, and occlusion. The presence of extensive lead-venous wall adherence (≥50 mm) was also assessed. A total of 105 patients (median age 71 years; 72% male) with a median of 2(1-2) leads to extract were enrolled. Preoperative venography showed moderate to severe stenosis in 31(30%), complete occlusion in 15(14%), and extensive lead-venous wall adherence in 50 (48%) patients. Complete TLE success was achieved in 103(98%) patients. Fifty-five (52%) were advanced extractions as they required a power mechanical and/or laser sheath. They were more prevalent in the group with extensive lead-venous wall adherence (72% vs. 34%, p<0.001), while no differences were found between patients with and without venous occlusion. In multivariate analysis, the presence of adherence was a predictor of advanced extraction (odds ratio 2.89[1.14-7.32], p=0.025). The fluoroscopy time was also significantly longer (14.0[8.2-18.7] vs. 5.1[2.1-10.0] min, p<0.001). The rate of complications did not differ based on the presence of venous lesions.

CONCLUSION

Although procedural success and complication rates were similar, patients with extensive lead-venous wall adherence required a longer fluoroscopy time and were 3 times more likely to need advanced extraction tools. Conversely, the presence of total venous occlusion had no impact on the procedure complexity. This article is protected by copyright. All rights reserved.

The role of transesophageal echocardiography in predicting technical problems and complications of transvenous lead extractions procedures

Background

Transesophageal echocardiography (TEE) is a useful tool in preoperative evaluation of patients undergoing transvenous lead extraction (TLE).

Hypothesis

Echocardiographic phenomena may determine the difficulty and safety of the procedure.

Methods

Data from 936 transesophageal examinations (TEE) performed at a high volume center in patients awaiting TLE from 2015 to 2019 were assessed.

Results

TEE revealed a total of 1156 phenomena associated with the implanted leads in 697 (64.85%) patients, including: asymptomatic masses on endocardial leads (AMEL) (58.65%), vegetations (12,73%), fibrous tissue binding the lead to the vein or heart wall (33.76%), lead‐to‐lead binding sites (18.38%), excess lead loops (19.34%), intramural penetration of the lead tip (16.13%) and lead‐dependent tricuspid dysfunction (LDTD) (6.41%). Risk factors for technical difficulties during TLE in multivariate analysis were: fibrous tissue binding the lead to atrial wall (OR = 1.738; p < 0.05), to right ventricular wall (OR = 2.167; p < 0.001), lead‐to‐lead binding sites (OR = 1.628; p < 0.01) and excess lead loops (OR = 1.488; p < 0.05). Lead‐to‐lead binding sites increased probability of major complications (OR = 3.034; p < 0.05). Presence of fibrous tissue binding the lead to the superior vena cava (OR = 0.296; p < 0.05), right atrial wall (OR = 323; p < 0.05) and right ventricular wall (OR = 0.297; p < 0.05) reduced the probability of complete procedural success, whereas fibrous tissue binding the lead to the tricuspid apparatus decreased the probability of clinical success (OR = 0.307; p < 0.05).

Conclusions

Careful preoperative TEE evaluation of the consequences of extended lead implant duration (enhanced fibrotic response) increases the probability of predicting the level of difficulty of TLE procedures, their efficacy and risk of major complications.

State-of-the-art narrative review: multimodality imaging in electrophysiology and cardiac device therapies

Cardiac electrophysiology procedures have evolved to provide improvement in morbidity and mortality for many patients. Cardiac resynchronization therapy (CRT), implantable cardioverter/defibrillator (ICD) placement and lead extraction procedures are proven procedures, associated with significant reductions in patient morbidity and mortality as well as improved quality of life. The applications and optimization of these therapies are an evolving field. The optimal use and outcomes of cardiac electrophysiology procedures require a multidisciplinary approach to patient selection, device selection, and procedural planning. Cardiac imaging using echocardiography plays a key role in selection of patients for CRT therapy, for guidance of left ventricular (LV) lead placement, and for optimization of atrioventricular pacing delays in patients with CRT. Cardiac computed tomography (CT) is an important tool in assessment of lead perforation, as well as assessing risk of lead extraction and procedural planning. Cardiac magnetic resonance imaging (MRI) is an important adjunct to transthoracic echocardiography for patient selection and risk stratification for defibrillator therapy for multiple disease states including ischemic cardiomyopathy, hypertrophic cardiomyopathy, cardiac sarcoidosis, and arrhythmogenic right ventricular cardiomyopathy (ARVC). Cardiac positron emission tomography (PET) is a useful adjunct to the diagnosis of device infections as well as inflammatory conditions including cardiac sarcoidosis. Our review attempts to summarize the contemporary roles of multimodality imaging in CRT therapy, ICD therapy and lead extraction therapy.

Usefulness of right ventriculography compared with computed tomography for ruling out the possibility of lead perforation before lead extraction

Purpose

High-risk patients can be identified by preprocedural computed tomography (CT) before lead extraction. However, CT evaluation may be difficult especially for lead tip identification due to artifacts in the leads. Selective right ventriculography (RVG) may enable preprocedural evaluation of lead perforation. We investigated the efficacy of RVG for identifying right ventricular (RV) lead perforation compared with CT in patients who underwent lead extraction.

Methods

Ninety-five consecutive patients who were examined by thin-section non-ECG-gated multidetector CT and RVG before lead extraction were investigated retrospectively. Newly recognized pericardial effusion after lead extraction was used as a reference standard for lead perforation. We analyzed the prevalence of RV lead perforation diagnosed by each method. The difference in the detection rates of lead perforation by RVG and CT was evaluated.

Results

Of the 115 RV leads in the 95 patients, lead perforation was diagnosed for 35 leads using CT, but the leads for 29 (83%) of those 35 leads diagnosed as lead perforation by CT were shown to be within the right ventricle by RVG. Three patients with 5 leads could not be evaluated by CT due to motion artifacts. The diagnostic accuracies of RVG and CT were significantly different (p < 0.001). There was no complication of pericardial effusion caused by RV lead extraction.

Conclusion

RVG for identification of RV lead perforation leads to fewer false-positives compared to non-ECG-gated CT. However, even in cases in which lead perforation is diagnosed, most leads may be safely extracted by transvenous lead extraction.

Characterization of Lead Adherence Using Intravascular Ultrasound to Assess Difficulty of Transvenous Lead Extraction

Background:

Clinical factors associated with development of intravascular lead adherence (ILA) are unreliable predictors. Because vascular injury in the superior vena cava-right atrium during transvenous lead extraction is more likely to occur in segments with higher degrees of ILA, reliable and accurate assessment of ILA is warranted. We hypothesized that intravascular ultrasound (IVUS) could accurately visualize and quantify ILA and degree of ILA correlates with transvenous lead extraction difficulty.

Methods:

Serial imaging of leads occurred before transvenous lead extraction using IVUS. ILA areas were classified as high or low grade. Degree of extraction difficulty was assessed using 2 metrics and correlated with ILA grade. Lead extraction difficulty was calculated for each patient and compared with IVUS findings.

Results:

One hundred fifty-eight vascular segments in 60 patients were analyzed: 141 (89%) low grade versus 17 (11%) high grade. Median extraction time (low=0 versus high grade=97 seconds, P <0.001) and median laser pulsations delivered (low=0 versus high grade=5852, P <0.001) were significantly higher in high-grade segments. Most patients with low lead extraction difficulty score had low ILA grades. Eighty-six percentage of patients with high lead extraction difficulty score had low IVUS grade, and the degree of transvenous lead extraction difficulty was similar to patients with low IVUS grades and lead extraction difficulty scores.

Conclusions:

IVUS is a feasible imaging modality that may be useful in characterizing ILA in the superior vena cava-right atrium region. An ILA grading system using imaging correlates with extraction difficulty. Most patients with clinical factors associated with higher extraction difficulty may exhibit lower ILA and extraction difficulty based on IVUS imaging.

Graphic Abstract:

A graphic abstract is available for this article.

Algorithm for the analysis of pre-extraction computed tomographic images to evaluate implanted lead-lead interactions and lead-vascular attachments

BACKGROUND

The number of lead extractions is growing because of the greater population and increasing age of individuals with a cardiac implantable electronic device. Lead extraction procedures can be complex undertakings with risk of significant mortality, and vascular tears in the superior vena cava are of greatest concern.

OBJECTIVE

The purpose of this study was to study whether a novel algorithm that analyzes pre-extraction computed tomographic (CT) images can determine the likelihood and location of lead-lead interactions and lead-vessel attachment within patients' venous vasculatures. This information can be used to identify potential case challenges in the planning stages.

METHODS

We developed an algorithm to estimate the presence and position of lead-lead interactions and lead-vessel adherences by tracking distance between the leads and distance between the lead and superior vena cava in a sample of 12 patients referred to the United Heart and Vascular Clinic for lead extractions due to infection (n = 5), lead failure (n = 5), and tricuspid regurgitation (n = 2).

RESULTS

Preliminary results indicate that the developed algorithm successfully identified lead-lead and lead-vascular attachments compared to review of CT images by medical experts.

CONCLUSION

With future validation and clinical implementation, this algorithm could aid physician preparedness by minimizing intraprocedural emergencies and may improve patient outcomes.

Computed Tomography-Guided Risk Assessment in Percutaneous Lead Extraction

OBJECTIVES

The aim of this study was to assess if pre-procedural computed tomography (CT) could identify high-risk operative features and predict increased procedural complexity.

BACKGROUND

Unpredictable lead adhesions can make lead extraction complicated. Adhesions are known to affect leads with longer indwelling time but can unpredictably affect newer leads.

METHODS

Consecutive patients who had CTs performed ≤90 days before their planned lead extraction (LE) were included. CTs were reviewed blinded to outcome according to a preset checklist. The outcome was a combined endpoint of procedural complexity and major complications.

RESULTS

Between January 1, 2015 and July 1, 2018, 143 patients underwent CT and LE. Median age was 68 years (interquartile range [IQR]: 54.4 to 76.5), and 35% were female. Median age of extracted leads was 111 months, and 126 (43%) were >10 years. CT detected lead perforation ≥5 mm (n = 13), <5 mm (n = 55), severe lead adhesions (n = 65), leads touching vessel wall >1 cm (n = 102), lead fracture (n = 8), and severe ipsilateral venous stenosis/occlusion (n = 36). The procedure was complex in 63 cases. There were 2 deaths, and 6 major complications. Patients with severe lead adhesions had more complex procedures (n = 36 vs 29; p = 0.04), whereas none of the other findings on CT were significantly associated with worse outcome. In patients with leads that had an indwelling time <10 years (n = 72), severe lead adhesions on CT was associated with worse outcome in multivariable analysis (odds ratio: 6.4; 95% confidence interval: 1.4 to 30.2; p = 0.02).

CONCLUSIONS

Pre-procedural CT can be used to locate severe lead adhesions in patients planned for lead extraction. In patients with indwelling leads <10 years, pre-procedural CT aids in identifying patients prone to complex extractions.

Lead Location as Assessed on Cardiac Computed Tomography and Difficulty of Percutaneous Transvenous Extraction

OBJECTIVES

This study sought to retrospectively investigate outcomes of lead extraction by using pre-operative computed tomography (CT) scans to identify risk of complicated lead extraction to aid in pre-procedural planning.

BACKGROUND

Transvenous lead extractions remain high-risk procedures requiring specialized operators, equipment, and surgical backup. Data are lacking for how to identify difficult lead extractions. CT scans, which can illustrate the proximity of the lead to adherent venous structures can potentially aid in identifying difficult lead extractions.

METHODS

All cases of patients who were undergoing transvenous lead extractions at the authors' institution between 2015 and 2018, who had a pre-operative CT scan prior to lead extraction, were reviewed. The images were retrospectively reviewed to examine adherence of leads to the surrounding vein and obtained procedural outcomes.

RESULTS

A total of 203 cases were reviewed of patients undergoing transvenous lead extraction who had a pre-operative CT scan, and scans were separated based on lead location in the superior vena cava, as assessed by CT imaging. Scans were divided into 3 groups: those in a central location or <1 cm adherence (n = 28); those that had at least 1 lead with tip adherent >1 cm (n = 137); or those that had at least 1 lead outside the vein contour (n = 38). Although there was only 1 serious complication requiring vascular surgery intervention, patients with at least 1 lead outside the vein contour required significantly longer procedural time (190.8 ± 86.6 min vs. 158.1 ± 73.7 min vs. 142.8 ± 52.2 min; p = 0.019) and fluoroscopy time (33.1 ± 24.2 min vs. 19.6 ± 18.4 min vs. 18.3 ± 16.4 min; p = 0.0006) than those with leads adhering >1 cm and centrally located leads, respectively.

CONCLUSIONS

Pre-operative CT scanning can identify difficult lead extractions prior to performing the procedure. This information may aid electrophysiologists in the planning of extraction procedures. Future prospective studies are needed to confirm these findings.

Hybrid Lead Extraction Technique: Combined Transatrial Laser Lead Extraction and Surgical Removal of Calcified Lesions

This report presents a new hybrid lead extraction technique combined with transatrial laser lead extraction and surgical removal of calcified lesions in a 50-year-old man with superior vena cava syndrome and bilateral subclavian vein occlusion caused by an abandoned lead, which had been infected for 11 years. (Level of Difficulty: Intermediate.).

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.

Lead Extraction Imaging

Lead extraction procedures have a low but real risk of major complications, such as superior vena cava tear and cardiac tamponade. Complications during lead removal are commonly related to lead binding sites, lead malposition, and lead perforation. Lead extraction imaging may indicate lead vascular binding sites, lead position, and perforation. Several imaging modalities are available, including chest radiograph, cardiac computed tomography, and echocardiography. The information provided by various imaging modalities will help assess the challenges of each lead extraction procedure and allows for better preprocedure planning.

Transvenous Lead Extraction: A Clinical Commentary for Anesthesiologists

With increasing use of cardiovascular implantable electronic devices, the need for lead extractions has increased to an annual volume of more than 10,000 extractions worldwide. This article provides a focused clinical commentary on the perioperative management, identification, and treatment of life-threatening complications associated with lead extractions. In addition, a summary of indications, techniques, and lead extraction complications is provided. Although uncommon, lead extractions are associated with a consistent rate of major procedure-related complications and mortality. Major life-threatening complications include vascular laceration, cardiac avulsion, hemothorax, pericardial effusion, and cardiac arrest. Comprehensive preoperative risk assessment and adequate planning and preparedness are crucial to decreasing all procedure-related adverse events. The location of the procedure (electrophysiology suite v hybrid operating room) and the nature of cardiac surgical backup are determined after meticulous risk stratification. In addition to decisions on vascular access, invasive monitoring, and modality of rhythm support, transesophageal echocardiography plays a crucial role in early diagnosis, timely management, and potential prevention of these complications.

Use of Preprocedural MDCT for Cardiac Implantable Electric Device Lead Extraction: Frequency of Findings That Change Management

OBJECTIVE

Five percent of cardiac implantable electric devices (CIEDs) are removed each year. Percutaneous extraction is preferred but can be complicated if the leads adhere to the vasculature or perforate. The goal of this study is to assess the frequency of findings on dedicated MDCT that alter preprocedural planning for percutaneous CIED extraction.

MATERIALS AND METHODS

One hundred patients with CIEDs who underwent MDCT before percutaneous lead extraction were analyzed. Major findings that could preclude percutaneous removal, including lead course and termination, were distinguished from moderately significant findings that could alter but not preclude percutaneous removal, including endofibrosis of leads to the vasculature, lead termination abnormalities, central vein stenosis, or thrombus. Incidental findings were characterized separately. Findings were correlated with preprocedural decisions, the extraction procedure performed, and procedural outcomes.

RESULTS

Twenty-six women and 74 men with 125 right ventricular leads, 84 right atrial leads, and 26 coronary venous leads were evaluated. Major findings were present in 7% of patients, including six patients with lead perforation and one with a lead coursing outside a tricuspid annuloplasty ring. Moderately significant findings of endothelial fibrosis were found in 78% of patients. The central veins were narrowed or occluded in 42% of patients, and thrombus was present in 2% of patients. Thirty-six percent of patients had incidental findings, and 4% of patients had unexpected findings requiring immediate inpatient attention.

CONCLUSION

MDCT performed before CIED lead extraction is able to identify major and moderately significant findings that can alter either percutaneous extraction or preprocedural planning. The use of dedicated preprocedural MDCT can help to stratify patient risk, guide decision making by the proceduralist, and identify non-catheter-related findings that affect patient management.

Long-Range Real Migration of Implantable Cardioverter Defibrillator Lead

The need for pacemaker and implantable cardioverter defibrillator (ICD) lead revisions and extractions is steadily increasing. Despite the lack of representative studies, the risk of lead extraction is frequently considered to be lower than leaving nonfunctional leads in situ.

We report the case of a patient who was referred to our institution for exchange of a malfunctioning ICD lead. The diagnostic work-up revealed a long-segment transmural migration of the ICD lead at the site of the subclavian and innominate vein. Due to the unpredictable risk of vein perforation, we abandoned the extraction procedure.