Cardiac and Vascular Injuries Sustained During Transvenous Lead Extraction

Safety and success of transvenous lead extraction using excimer laser sheaths: a meta-analysis of over 1700 patients

AIMS

While numerous studies have demonstrated favourable safety and efficacy of the excimer laser sheath for transvenous lead extraction (TLE) in smaller cohorts, comprehensive large-scale investigations with contemporary data remain scarce. This study aims to evaluate the safety and performance of laser-assisted TLE through a meta-analysis of contemporary data.

METHODS AND RESULTS

A systematic literature search was conducted to identify articles that assessed the safety and performance of the spectranetics laser sheath (SLS) II and GlideLight Excimer laser sheaths in TLE procedures between 1 April 2016 and 31 March 2021. Safety outcomes included procedure-related death and major/minor complications. Performance outcomes included procedural and clinical success rates. A random-effects, inverse-variance-weighting meta-analysis was performed to obtain the weighted average of the evaluated outcomes. In total, 17 articles were identified and evaluated, including 1729 patients with 2887 leads. Each patient, on average, had 2.3 ± 0.3 leads with a dwell time of 7.9 ± 3.0 years. The TLE procedural successes rate was 96.8% [1440/1505; 95% CI: (94.9-98.2%)] per patient and 96.3% [1447/1501; 95% CI: (94.8-97.4%)] per lead, and the clinical success rate per patient was 98.3% [989/1010, 95% CI: (97.4-99.0%)]. The procedure-related death rate was 0.08% [7/1729, 95% CI: (0.00%, 0.34%)], with major and minor complication rates of 1.9% [41/1729; 95% CI: (1.2-2.8%)] and 1.9% [58/1729; 95% CI: (0.8-3.6%)], respectively.

CONCLUSION

This meta-analysis demonstrated that excimer laser sheath-assisted TLE has high success and low procedural mortality rates. It provides clinicians with a reliable and valuable resource for extracting indwelling cardiac leads which require advanced extraction techniques.

Single center experience with the novel rotating dilator sheath TightRailTM Sub-C in transvenous lead extraction

INTRODUCTION

Transvenous lead extraction has become a frequent procedure in the context of device lead management and various tools are available. The aim of this study was to investigate the efficacy and safety of the novel short rotating dilator sheath TightRailTM Sub-C (Sub-C) in transvenous lead extraction.

METHODS

For this retrospective single-center analysis, we included consecutive patients undergoing transvenous lead extraction using the Sub-C from January 2018 until February 2020 at the University Heart Center Zurich.

RESULTS

A total of 87 leads were extracted within 45 patients using the Sub-C extraction sheath. The mean dwell time of the leads was 112 ± 9.1 months. Complete procedural success was achieved in 95.6% (43/45) and clinical procedural success in 97.8% (44/45). Two major complications (4.4%, 2/45) occurred, but neither was directly related to the Sub-C.

CONCLUSION

This retrospective single-center analysis suggests that transvenous lead extraction with a routine use of the TightRailTM Sub-C extraction sheath is a safe strategy resulting in high success rates that may offer useful theoretical benefits. Future studies are needed to evaluate the incremental benefit of a routine use of short extraction sheaths including the Sub-C during TLE procedures.

Long-term outcomes of non-systematic device reimplantation following lead extraction in selected patients

Following the removal of cardiovascular implantable electronic devices (CIEDs), reassessment of the need for a new device is vital. Some patients may have exhibited an improvement in rhythm or cardiac function and may thus no longer meet the guideline requirements for reimplantation. However, the long-term outcomes of non-systematic device reimplantation remain unknown. In the present study, it was hypothesized that the implantation of pacing systems in selected patients following lead extraction is safe. In order to confirm this hypothesis, a total of 854 patients (aged between 28 and 82 years) who underwent the removal of a CIED were enrolled in the present study and they were all reassessed to determine whether a new device following lead extraction was necessary. In order to determine which patients would undergo non-systematic device reimplantation, the standard guidelines, the criteria and the wishes of the patient were all taken into consideration. Patients remained device-free unless an adverse clinical event occurred that required reimplantation. The primary study endpoint was the rate of sudden death or reimplantation. Between January, 2014 and December, 2019, 854 consecutive patients underwent pacing system extraction, of whom 210 patients (24.6%) underwent non-systematic device reimplantation following careful reassessment (the non-reimplantation group). Among the 210 patients, 162 (77.1%) were fitted with pacemakers, 26 (12.4%) underwent cardiac resynchronization therapy or cardiac resynchronization therapy-defibrillator and 22 (10.5%) were implanted with a cardioverter-defibrillator. During a mean follow-up period of 40.4 months, 86 patients reached the primary endpoint of the study, including 54 out of 210 patients (25.7%) who experienced an adverse clinical event that required reimplantation and 32 out of 210 patients (15.2%) who experienced sudden death. Reimplantation of a new device was not required in ~25% of the patients. On the whole, the present study demonstrates that following pacing system removal, non-systematic device reimplantation associated with close surveillance is safe for selected patients.

Characterization of Lead Adherence Using Intravascular Ultrasound to Assess Difficulty of Transvenous Lead Extraction

Background:

Clinical factors associated with development of intravascular lead adherence (ILA) are unreliable predictors. Because vascular injury in the superior vena cava-right atrium during transvenous lead extraction is more likely to occur in segments with higher degrees of ILA, reliable and accurate assessment of ILA is warranted. We hypothesized that intravascular ultrasound (IVUS) could accurately visualize and quantify ILA and degree of ILA correlates with transvenous lead extraction difficulty.

Methods:

Serial imaging of leads occurred before transvenous lead extraction using IVUS. ILA areas were classified as high or low grade. Degree of extraction difficulty was assessed using 2 metrics and correlated with ILA grade. Lead extraction difficulty was calculated for each patient and compared with IVUS findings.

Results:

One hundred fifty-eight vascular segments in 60 patients were analyzed: 141 (89%) low grade versus 17 (11%) high grade. Median extraction time (low=0 versus high grade=97 seconds, P <0.001) and median laser pulsations delivered (low=0 versus high grade=5852, P <0.001) were significantly higher in high-grade segments. Most patients with low lead extraction difficulty score had low ILA grades. Eighty-six percentage of patients with high lead extraction difficulty score had low IVUS grade, and the degree of transvenous lead extraction difficulty was similar to patients with low IVUS grades and lead extraction difficulty scores.

Conclusions:

IVUS is a feasible imaging modality that may be useful in characterizing ILA in the superior vena cava-right atrium region. An ILA grading system using imaging correlates with extraction difficulty. Most patients with clinical factors associated with higher extraction difficulty may exhibit lower ILA and extraction difficulty based on IVUS imaging.

Graphic Abstract:

A graphic abstract is available for this article.