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LEAD EXTRACTION: INDICATIONS AND TECHNIQUES.
Maria Grazia Bongiorni
Direttore Unità Operativa Malattie Cardiovascolari 2, Azienda Ospedaliero-Universitaria, Pisa. Italia
In recent years, the significant expansion of implanted devices for cardiac pacing and defibrillation increased the number of device-related complications and, consequently, the need for removal.
Infection of the implanted systems, either local or systemic, cannot be effectively managed by drug therapy or surgical revisions, requiring in most cases the removal of the whole systems, leads and generator. Moreover, lead malfunction often requires the removal of damaged leads, particularly in young patients or in presence of ICD devices.
Indications to lead extraction, previously described as mandatory, necessary and discretionary, were refined in 2000 and published in the format established for the American College of Cardiology/American Heart Association’s methodology for practice guidelines (Class I, Class II and Class III). Very recently (July 2009) Recommendations were uploaded and published as HRS Consensus Expert.
Over the past two decades, although extraction techniques have evolved from simple traction to extraction with dilator and powered sheaths with reported success rates up to 95%, percutaneous lead removal has been still associated with a small but significant procedural failure, morbidity and mortality.
As known, fibrotic tissue develops over time and entraps the implanted lead in the veins and in the cardiac chambers. However, conventional techniques including the use of a locking stylet, telescoping or powered sheath advancement over leads and lead removal through the venous entry site are sometimes not able to overcome common procedural difficulties, causing failure and/or complications.
According to these observations, since 1997 we have been developing a modified percutaneous mechanical dilatation technique to overcome procedural difficulties, improving success rate and reducing complications.
Personal Experience on Transvenous Lead Extraction
We developed a single mechanical dilating sheath extraction technique with multiple venous entry site approaches. We performed a Venous Entry Approach (VEA) in case of exposed leads and an alternative transvenous femoral approach (TFA) combined with an Internal Transjugular Approach (ITA) in the presence of very tight binding sites causing failure of VEA extraction or in case of free-floating leads. We submitted to removal 2062 leads (1825 pacing and 237 ICD leads; 1989 exposed at the venous entry site and 73 free-floating leads) in 1193 consecutive patients. The VEA was effective in 1799 leads, the TFA in 28 and the ITA in 205; in the overall population we completely removed 2032 leads (98.4%), partially removed 18 (0.9%) and failed to remove 12 leads (0.6%). Major complications were observed in 8 patients (0.7%), causing 3 deaths (0.3%).
Mechanical single sheath extraction technique with multiple venous entry site approaches is effective, safe and with a good cost effective profile for pacing and ICD leads removal.
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