Reflections of six years of lead extraction: influence on indications and technique

Endovascular techniques have become the standard approach for extraction of pacemaker and ICD leads. However, with experience, the indications and technical approach have evolved.

In a population referred for lead extraction, we could not found a relation between the number of leads implanted and the incidence of occlusion of the access vein. Moreover, there is evidence that the lead extraction itself is accompanied with an increased risk of post-procedural venous occlusion. Electrical interference can be avoided in most cases, even in ICD patients. As complications of extraction have to be taken into account as well, it is therefore not in the patient's interest to extract chronically implanted non-functional superfluous leads. In contrast, lead extraction is a most effective way to cure pacemaker or ICD related infections, even if previous conservative therapy has failed. However, in patients at high risk, extraction might be deferred to attempt device saving therapy first.

Although leads can be removed with traction for almost all implant times, after six months additional tools are increasingly necessary to safely and completely extract them. No single technique suffices for all procedures: powered sheaths - as the laser sheath - and a femoral workstation with retrievers should be available when extraction is attempted.

Venous or myocardial perforation is a life-threatening complication of lead extraction. In these circumstances, time lacks to safely transfer a patient for emergency surgery and therefore the only safe environment to perform lead extraction is the operating theatre with cardiosurgical standby.