Physicians reporting 15 years of experience in extracting implantable cardioverter defibrillator (ICD) leads with a mechanical single-sheath technique and a multiple venous entry-site approach say they have found it is a complex but safe procedure, with a 99% success rate and no major complications.
The retrospective study, recently published ahead-of-print in Europace, by Maria Grazia Bongiorni and colleagues (University Hospital of Pisa, Pisa, Italy) evaluates procedures and outcomes for 545 consecutive patients referred at their institution for extraction of 582 ICD leads between 1997 and 2012.
The authors describe that in the technique-they developed in 1997- they performed an initial attempt at manual traction. If this resulted unsuccessful, they used a single-sheath approach with progressive dilatation inserting and advancing dilatators (from Cook Vascular) through the venous entry-site. Finally, they considered an internal transjugular approach when dilatation was ineffective or judged too risky.
Bongiorni et al report that in this study simple manual traction was effective in 35 leads (6%). Mechanical dilation through the venous entry was effective in 484 cases (83%) and successful extraction through the internal jugular vein was achieved in 58 cases (10%). “Thus, the success rate increased from 6% with manual traction to 89% through the venous entry-site mechanical dilation approach, and reached an overall value of 99% (577 out of 582) when mechanical dilatation was attempted via the internal jugular vein,” they authors note.
They also report that dwell-time, a passive fixation mechanism and dual-coil lead design were independently associated with the need for mechanical dilatation, but only dwell-time was associated with crossover to the internal jugular approach. A dwell-time of 20 months best predicted the need for venous entry-site mechanical dilatation, while a value of 55 months predicted crossover to the internal jugular approach.
Bongiorni et al write: “A longer lead dwell-time is associated with the need for mechanical dilatation and for crossover to the internal jugular approach. This should be considered when planning the removal procedure. Moreover, passive fixation and dual-coil lead design predict a more challenging extraction procedure. Thus, an implantable cardioverter defibrillator lead with these characteristics should be considered for implantation only after careful evaluation of the expected benefits and possible risks.”
A total of five leads could not be removed over the period evaluated. Three leads fractured and two proved to be firmly encapsulated in fibrotic tissue at the level of the distal coil. In four cases, the leads were left in situ with no complications reported, and in the fifth the patient was referred to a cardiac surgeon for open-chest extraction.
The mean extraction time was eight minutes, ranging from one minute to 210 minutes. There were no major complications associated with lead extraction. Some minor complications were reported including pericardial effusion in two patients, sustained ventricular tachycardia in five patients, sustained atrial fibrillation in five patients and haematoma at the pocket requiring drainage in five patients. Four patients required blood transfusion, while pneumothorax occurred in one patient and lead dislodgement in one patient.
The authors highlight that this is the largest published single centre experience in ICD lead extraction and encompasses a wide range of ICD models that are still in use.
“Although complex, the mechanical transvenous extraction of ICD leads is a safe and effective procedure,” they conclude.