2017 HRS expert consensus statement on cardiovascular implantable electronic device lead management and extraction. Heart Rhythm. 2017;14:e503-e551. [PMID: 28919379 DOI: 10.1016/j.hrthm.2017.09.001]

Venous System Interventions for Device Implantation

Subclavian obstruction is common after lead implantation and the need to add or replace a lead is increasing. Subclavian venoplasty (SV) is a safe and effective option for venous occlusion. Peripheral venography overestimates the severity of the obstruction. A wire can usually be advanced into the central circulation for SV. Compared with dilators, SV improves the quality of venous access, providing unrestricted catheter manipulation for His bundle pacing and left ventricular lead implantation. SV preserves venous access and reduces lead burden. SV can easily be added to the implanting physicians lead management options.

Lead Management and Lead Extraction

Management of patients with cardiac implantable electronic devices (CIEDs) has become complex given the complications that can occur with implanted lead systems. Clinical problems such as infection, lead failure, and occluded vessels create situations that demand intervention to remove leads. Due to adhesions that occur in the venous system and at the endomyocardial attachment site, simple traction to remove a lead is often not sufficient. Infection is a mandatory reason to remove the entire CIED system. Tools and techniques are now available that enable a skilled operator to extract leads with a great deal of efficacy and safety.

Transvenous Lead Extraction: A Clinical Commentary for Anesthesiologists

With increasing use of cardiovascular implantable electronic devices, the need for lead extractions has increased to an annual volume of more than 10,000 extractions worldwide. This article provides a focused clinical commentary on the perioperative management, identification, and treatment of life-threatening complications associated with lead extractions. In addition, a summary of indications, techniques, and lead extraction complications is provided. Although uncommon, lead extractions are associated with a consistent rate of major procedure-related complications and mortality. Major life-threatening complications include vascular laceration, cardiac avulsion, hemothorax, pericardial effusion, and cardiac arrest. Comprehensive preoperative risk assessment and adequate planning and preparedness are crucial to decreasing all procedure-related adverse events. The location of the procedure (electrophysiology suite v hybrid operating room) and the nature of cardiac surgical backup are determined after meticulous risk stratification. In addition to decisions on vascular access, invasive monitoring, and modality of rhythm support, transesophageal echocardiography plays a crucial role in early diagnosis, timely management, and potential prevention of these complications.

A Novel "Trouserslike" Technique for the Extraction of 22-Year-Old Pacemaker Leads

Cardiac management devices have become an integral part of our armament for treatment of heart diseases. However, complications may arise that mandate extraction of either the device or the lead. The noninterventional lead extraction has become a topic of avid debate as simple traction is associated with low success rates whereas laser-assisted extraction carries a high economic cost. Herein we present a case of 22-year-old pacemaker leads extracted with a novel "trouserslike technique" that could present an attractive alternative for leads implanted for more than 10 years when laser sheaths are not accessible.