Cardiovascular implantable electronic device lead extraction: evidence, techniques, results, and future directions

Cardiovascular implantable electronic devices are widely used to treat symptomatic arrhythmias, prevent sudden cardiac death, and improve symptoms and cardiac function. Continued population growth and expanding indications have resulted in a progressive increase in the number of cardiovascular implantable electronic device implantations. Mirroring this growth, an increasing number of leads require removal because of a variety of indications. Transvenous lead extraction continues to evolve with better techniques and risk-management strategies. This review highlights the indications, techniques, procedural outcomes, and future directions of arrhythmia device management and extraction.

Indications for extractions are reviewed in light of newly published data. Same day contralateral reimplantation has been shown to be safe in patients with localized pocket infection. Alternative extraction techniques, utilizing the femoral and internal jugular veins, provide additional routes for device removal as stand-alone procedures or in cases of difficult extraction via the subclavian vein. Preprocedural imaging to identify adherence sites and cardiac perforation can help to reduce complications. Routine capsulectomy at generator change does not seem to reduce the risk of device infection, and multiple trials are underway to assess other methods of reducing infections as part of a lead management strategy.

Improvement in technology, alternative routes of extraction and preprocedural imaging continue to add to procedural efficacy and reduce complication rates of lead extraction.