Upper Extremity Deep Vein Thrombosis and Asymptomatic Vein Occlusion in Patients With Transvenous Leads: A Systematic Review and Meta-Analysis

Aims: The presence of transvenous leads for cardiac device therapy may increase the risk of venous thromboembolisms. The epidemiology of these complications has not yet been determined systematically. Therefore, this study aims to determine (I) the incidence of symptomatic upper extremity deep vein thrombosis (UEDVT) and (II) the prevalence of asymptomatic upper extremity vein occlusion in patients with transvenous leads, both after the initial 2 months following lead implantation.

Methods: PubMed, EMBASE, and Cochrane Library were searched until March 31, 2020 to identify studies reporting incidence of UEDVT and prevalence of asymptomatic vein occlusion after the initial 2 months after implantation in adult patients with transvenous leads. Incidence per 100 patient years of follow-up (PY) and proportions (%) were calculated to derive pooled estimates of incidence and prevalence.

Results: Search and selection yielded 20 and 24 studies reporting on UEDVT and asymptomatic vein occlusion, respectively. The overall pooled incidence of UEDVT was 0.9 (95% CI 0.5–1.4) per 100PY after 2 months after lead implantation. High statistical heterogeneity was present among studies (I² = 82.4%; P = < 0.001) and only three studies considered to be at low risk of bias. The overall pooled prevalence of asymptomatic upper extremity vein occlusion was 8.6% (95% CI 6.0–11.5) with high heterogeneity (I² = 81.4%; P = <0.001). Meta-regression analysis showed more leads to be associated with a higher risk of UEDVT.

Conclusion: Transvenous leads are an important risk factor for symptomatic UEDVT, which may occur up to multiple years after initial lead implantation. Existing data on UEDVT after lead implantation is mostly of poor quality, which emphasizes the need for high quality prospective research. Asymptomatic vein occlusion is present in a substantial proportion of patients and may complicate any future lead addition.

Clinical Trial Registration: (URL: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020178136, Identifier: PROSPERO 2020 CRD42020178136).

Neointimal fibrotic lead encapsulation - Clinical challenges and demands for implantable cardiac electronic devices

Every tenth patient with a cardiac pacemaker or implantable cardioverter-defibrillator implanted is expected to have at least one lead problem in his lifetime. However, transvenous leads are often difficult to remove due to thrombotic obstruction or extensive neointimal fibrotic ingrowth. Despite its clinical significance, knowledge on lead-induced vascular fibrosis and neointimal lead encapsulation is sparse. Although leadless pacemakers are already available, their clinical operating range is limited. Therefore, lead/tissue interactions must be further improved in order to improve lead removals in particular. The published data on the coherences and issues related to lead associated vascular fibrosis and neointimal lead encapsulation are reviewed and discussed in this paper.

Outcomes Associated With Extraction Versus Capping and Abandoning Pacing and Defibrillator Leads

Background:

Lead management is an increasingly important aspect of care in patients with cardiac implantable electronic devices; however, relatively little is known about long-term outcomes after capping and abandoning leads.

Methods:

Using the 5% Medicare sample, we identified patients with de novo cardiac implantable electronic device implantations between January 1, 2000, and December 31, 2013, and with a subsequent lead addition or extraction ≥12 months after the de novo implantation. Patients who underwent extraction for infection were excluded. Using multivariable Cox proportional hazards models, we compared cumulative incidence of all-cause mortality, device-related infection, device revision, and lead extraction at 1 and 5 years for the extraction versus the cap and abandon group.

Results:

Among 6859 patients, 1113 (16.2%) underwent extraction, whereas 5746 (83.8%) underwent capping and abandonment. Extraction patients tended to be younger (median, 78 versus 79 years; P <0.0001), were less likely to be male (65% versus 68%; P =0.05), and had shorter lead dwell time (median, 3.0 versus 4.0 years; P <0.0001) and fewer comorbidities. Over a median follow-up of 2.4 years (25th, 75th percentiles, 1.0, 4.3 years), the overall 1-year and 5-year cumulative incidence of mortality was 13.5% (95% confidence interval [CI], 12.7–14.4) and 54.3% (95% CI, 52.8–55.8), respectively. Extraction was associated with a lower risk of device infection at 5 years relative to capping (adjusted hazard ratio, 0.78; 95% CI, 0.62–0.97; P =0.027). There was no association between extraction and mortality, lead revision, or lead extraction at 5 years.

Conclusions:

Elective lead extraction for noninfectious indications had similar long-term survival to that for capping and abandoning leads in a Medicare population. However, extraction was associated with lower risk of device infections at 5 years.

Outcomes 1 Year After Implantable Cardioverter-Defibrillator Lead Abandonment Versus Explantation for Unused or Malfunctioning Leads: A Report from the National Cardiovascular Data Registry

BACKGROUND

Patients with an unused or malfunctioning implantable cardioverter-defibrillator (ICD) lead may have the lead either abandoned or explanted; yet there are limited data on the comparative acute and longer-term safety of these 2 approaches.

METHODS AND RESULTS

We examined in-hospital events among 24 908 subject encounters using propensity score 1:1 matching for ICD lead abandonment or explantation in the National Cardiovascular Data Registry (NCDR) ICD Registry (April 2010 to June 2014). Relative to patients undergoing lead abandonment, patients undergoing lead explantation had more in-hospital procedure-related complications: 2.19% (n=273) versus 3.77% (n=469; P<0.001), respectively. Similarly, patients undergoing lead explantation had slightly higher rates of in-hospital death: 0.21% (n=26) versus 0.64% (n=80; P<0.001), respectively. At 1 year in a Medicare subset for survival, there was a trend of increased mortality in the explantation group (11% versus 8%; P=0.06). In the Medicare subset analyzed for postprocedure complications, there was no difference with respect to 6-month bleeding (4.80% in both the groups), tamponade (0.38% versus 0.58%), infection (1.34% versus 3.07%), upper extremity thrombosis (0.77% versus 0.96%), pulmonary embolism (0.38% versus 0.96%), or urgent surgery (1.15% for both the groups; P>0.05 for all).

CONCLUSIONS

After matching, patients undergoing removal of an unused or malfunctioning ICD lead had slightly higher in-hospital complications and deaths than those with a lead abandonment strategy. Although the 1-year mortality risk was slightly higher in the lead explantation group, this difference was not statistically significant and may be explained by chance.

Frequency and clinical impact of retained implantable cardioverter defibrillator lead materials in heart transplant recipients

End-stage heart failure patients with implantable cardioverter-defibrillator (ICD) with/without cardiac resynchronization therapy (CRT-D) often require heart transplantation (HTPL) as a last-resort treatment. We aimed to assess the frequency and clinical impact of retained ICD lead materials in HTPL patients. In this retrospective single center study, we examined the clinical records and chest radiographs of patients with ICD and CRT-D who underwent HTPL between January 1992 and July 2014. Of 40 patients with ICD and CRT-D at HTPL, 19 (47.5%) patients had retained ICD lead materials within the central venous system. Retained ICD lead materials following HTPL were more frequently noted in patients with longer implantation durations until HTPL. None of the patients underwent extraction procedures after HTPL. All patients were asymptomatic and did not exhibit significant complications or death related to the retained ICD lead materials. Seven (7/40, 17.5%) patients without any retained ICD lead materials underwent magnetic resonance imaging (MRI) during the follow-up period (median, 29.5 months); none of the patients with retained lead materials were given MRI. Considering the common use of MRI in HTPL patients, further studies on the prophylactic extraction of retained ICD lead materials and safety of MRI in these patients are needed.

Managing patients with advisory defibrillator leads: what can we learn from published data?

Defibrillator lead advisories stir a lot of emotions, both with patients and physicians, and this may influence lead management. We reviewed the literature for a more evidence-based approach to this issue.

From the complications of two of the current advisory leads, the Medtronic Sprint Fidelis and St. Jude Riata leads, and the consequences of possible interventions, we can conclude that a restrained approach to premature replacement is appropriate. It may be opportune to replace the leads during a scheduled generator replacement in case of a higher electrical failure rate, in order to prevent future premature interventions.

We found no support to extract non-functional advisory leads. In contrast, extraction is often more demanding than anticipated, and the risk substantially exceeds that of simply abandoning the leads.

Prevalence of venous occlusion in patients referred for lead extraction: implications for tool selection

AIMS

Data concerning the incidence of venous obstruction in patients referred for lead extraction is limited. Thus, we aimed to assess the incidence of venous obstruction in patients referred for lead extraction and the implications for tool selection.

METHODS AND RESULTS

Contrast venography of the access vein was obtained in 202 patients (147 men; mean age, 62.4 ± 14.5 years) scheduled for lead extraction. The indication for lead extraction included infection (n = 145, 72%) and other causes (n = 57, 28%). Two patients with device infection had superior vena caval occlusion. Access vein occlusion occurred in 6 (11%) patients without infection vs. 46 (32%) patients with infection [P = 0.002; odds ratio (OR) 3.94; 95% confidence interval (CI) 1.58-9.87]. No significant differences between occluded and non-occluded patients were seen for age, sex, device type, number of leads, time from implant of the initial lead, or anticoagulation therapy (all P>0.05). Procedural duration and fluoroscopy exposure time were significantly lower in the open group than in the occluded group (P < 0.05). Patients with venous occlusion required more advanced tools for lead extraction, such as dilator sheaths, evolution sheaths, and needle's eye snares (P = 0.019).

CONCLUSION

Both systemic and local infections are associated with increased risk of access vein occlusion. We found no support for the hypothesis that venous occlusion increases with the number of leads present. Lead extraction was more difficult in patients with venous occlusion, requiring advanced tools and more time.

Extraction of chronically implanted cardiovascular electronic device leads

OPINION STATEMENT

Cardiovascular implantable electronic devices (CIED) are a remarkable success story. These systems are widely used to prevent symptomatic bradycardia, treat malignant tachyarrhythmia, and to restore a more physiologic contraction to a failing left ventricle. Implantation of a CIED usually involves a lifelong commitment to this therapy, which, unfortunately, is not free from complication requiring removal and/or replacement of all or part of the system. The major obstacle to removal of a CIED is the fibrous attachments that develop between a lead and co-existent leads, veins, and the heart. This process increases over time such that, by one year, removal by traction alone may be problematic and, if aggressive, result in complication. Physicians, surgeons, and engineers have refined techniques of percutaneous lead extraction and developed tools, which have facilitated the process, increased success, and lowered the incidence of complication. Extraction may be performed for a variety of indications some of which are unanimously agreed upon while others remain controversial. Proponents of a broadened application of extraction have proffered the concept of 'lead management,' which includes the removal of all leads that are not clinically relevant to the patient. The benefit of this approach would be to limit the risk of future complication, such as venous occlusion or thromboembolism, and to obviate the increase in difficulty of extraction (due to longer implant duration) that might accompany removal should that be required in the future. Intuitively appealing as this approach might be, there is little evidence supporting it, and the extraordinarily large number of patients currently implanted with recalled ICD leads is indicative of the potential impact this practice may have. This review will discuss extraction, its indications, and outcomes.