HANDS ON How to select patients for lead extraction Michael E. Field, MD, Samuel O. Jones, MD, Laurence M. Epstein, MD From the Arrhythmia Unit, Cardiovascular Division, Brigham and Women’s Hospital. Introduction The techniques and tools for percutaneous removal of trans- venous leads have undergone substantial development over the past several decades. Although the use of locking stylets and powered sheaths to free leads from encapsulated scar tissue has improved the success rate, the procedure still carries a significant risk of morbidity and mortality even in the hands of experienced operators. The threshold for lead extraction continues to evolve. The initial use of the proce- dure was limited to patients with life-threatening infections because of limited tools, lower success rates and high com- plication rates. Improved technology has increased the suc- cess rate and allowed indications to expand. The dramatic growth in implantation of cardiac devices has resulted in an exponential increase in the number of implanted leads. Unfor- tunately this increase in implantation has also occurred at a time of increasing device advisories and recalls. 1,2 Additional demand for lead extraction has occurred with the need to upgrade pacing systems to implantable cardioverter defibril- lators (ICDs) and resynchronization devices in the setting of venous occlusion. Extraction of a chronically implanted lead should be performed by an experienced operator only after careful consideration of the individual risk/benefit ra- tio. This article will discuss the risks, indications, and es- sential requirements for lead extraction. The techniques of lead extraction will be discussed in a separate article. Procedural risk The risk associated with lead extraction has largely dictated the indications for removal. Therefore the risks will be reviewed prior to discussing the indications. Complication rates The rate of major complications associated with lead ex- traction, including death, can be estimated from numerous registries. Byrd et al 3 published the experience with lead extraction using laser-powered sheaths during a period be- tween 1995 and 1999 on 1,684 patients. The overall rate of major complications (tamponade, hemothorax, pulmonary embolism, lead migration, and death) was 1.9% with an in-hospital mortality rate of 0.8%. Kay et al 4 reported the complication rate from 4,023 patients who underwent elec- tive extraction following the voluntary recall of the Telec- tronics Accufix atrial ‘J’ lead. The rate of major complica- tion associated with extraction was around 2% with a mortality rate of 0.4% (usually as a result of either central venous tear or myocardial perforation). The major compli- cation rates across multiple registries are varied, ranging from 0.6 to 3.3%, and can generally be attributed to patient- specific risk factors and operator experience. 5 It is important to not extrapolate an individual’s risk of complications from those in the published registries, which consisted of primar- ily experienced operators doing a high volume of proce- dures. Patient-specific risk factors A newly placed lead will develop thrombus, which over time can form points of fibrous attachment to intravascular and cardiac structures. The common binding areas are at the site of entry of the lead into the subclavian/axillary vein, especially under the clavicle, at the superior vena cava-right atrial junction, and at the distal electrode-cardiac interface. In addition, there is often significant lead-lead binding in patients with multiple leads and along each of the shocking coils/electrodes of ICD leads. The difficulty of lead removal and likelihood of complica- tion relate to a number of identifiable risk factors, the most important of which is duration of lead implant. In general, the longer a lead has been implanted, the more difficult it is to remove. In a single series, all leads implanted for less than six months could be removed with manual traction alone. 6 In the pre-powered sheath era, the risk of failed extraction doubled with each 3 years of implant duration. 7 Data from the Accufix registry demonstrated that the risk of a major complication increased progressively with implant dura- tion. 4 Generally, leads in place for less than one year can usually be removed without much difficulty. Other risk factors that portend difficult lead removal and/or complication include physician inexperience, younger patient age, 8 female sex, 3,4 presence of calcification involving the leads noted on chest radiograph, and presence of multiple leads (due to lead-lead binding). ICD leads appear riskier to re- move due to increased size and complexity. The coils in KEYWORDS Device removal; Lead extraction; Cardiac device infection; Permanent pacemaker; Implantable cardioverter-defibrillator (Heart Rhythm 2007;4:978 –985) Address reprint requests and correspondence: Dr. Laurence Epstein, Brigham and Women’s Hospital, Cardiovascular Division, 75 Francis Street, Tower 3A, Boston, MA 02115. email: lmepstein@partners.org. 1547-5271/$ -see front matter © 2007 Heart Rhythm Society. All rights reserved. doi:10.1016/j.hrthm.2007.05.022