The Influence of Lead-Related Venous Obstruction on the Complexity and Outcomes of Transvenous Lead Extraction

Lead Extraction-Indications, Procedure, and Future Directions

Cardiac implantable electronic device (CIED) implantation has steadily increased in the United States owing to increased life expectancy, better access to health care, and the adoption of updated guidelines. Transvenous lead extraction (TLE) is an invasive technique for the removal of CIED devices, and the most common indications include device infections, lead failures, and venous occlusion. Although in-hospital and procedure-related deaths for patients undergoing TLE are low, the long-term mortality remains high with 10-year survival reported close to 50% after TLE. This is likely demonstrative of the increased burden of comorbidities with aging. There are guidelines provided by various professional societies, including the Heart Rhythm Society, regarding indications for lead extraction and management of these patients. In this paper, we will review the indications for CIED extraction, procedural considerations, and management of these patients based upon the latest guidelines.

Cardiac Implantable Electronic Devices in Ischemic Cardiomyopathy

This review discusses the range of device therapy for ischemic cardiomyopathy (ICM). This article will review the primary data supporting guideline indications for cardiac implantable electronic devices in patients with ICM, with a focus on primary/secondary prevention transvenous implantable cardioverter defibrillators (ICDs), cardiac resynchronization therapy, and subcutaneous/extravascular ICDs. In addition, this review discusses emerging device therapy for ICM including left bundle area pacing/defibrillation, cardiac contractility modulation and baroflex activation therapy. Device therapy for ICM continues to evolve to incorporate diverse modalities across the spectrum from prevention of sudden cardiac death to modifying cardiac remodeling and recovery.

A hazardous collateral pathway following asymptomatic lead-related venous occlusion?

Routine venography should be performed before the device upgrade. Clinicians should not be unconcerned because of the lack of symptoms following lead-related venous occlusion. Knowledge of collateral anatomy is essential for future interventional plans. The venous pathway's return to the right atrium may entail risks to patient outcomes.

Case Series and Review of Literature for Superior Vena Cava Injury During Laser Lead Extraction

Transvenous laser lead extraction poses a risk of major complications (0.19%-1.8%), notably injury to the superior vena cava (SVC) in 0.19% to 0.96% of cases. Various factors contribute to SVC injury, which can be categorized as patient-related (such as female gender, low body mass index, diabetes, renal problems, anemia, and reduced ejection fraction), device-related (including the number, dwell time, and type of leads), or procedural-related (such as reason for extraction, venous obstructions, and bilateral lead placements).

Multilevel Venous Obstruction in Patients with Cardiac Implantable Electronic Devices

Background and Objectives: The nature of multilevel lead-related venous stenosis/occlusion (MLVSO) and its influence on transvenous lead extraction (TLE) as well as long-term survival remains poorly understood. Materials and Methods: A total of 3002 venograms obtained before a TLE were analyzed to identify the risk factors for MLVSO, as well as the procedure effectiveness and long-term survival. Results: An older patient age at the first system implantation (OR = 1.015; p < 0.001), the number of leads in the heart (OR = 1.556; p < 0.001), the placement of the coronary sinus (CS) lead (OR = 1.270; p = 0.027), leads on both sides of the chest (OR = 7.203; p < 0.001), and a previous device upgrade or downgrade with lead abandonment (OR = 2.298; p < 0.001) were the strongest predictors of MLVSO. Conclusions: The presence of MLVSO predisposes patients with cardiac implantable electronic devices (CIED) to the development of infectious complications. Patients with multiple narrowed veins are likely to undergo longer and more complex procedures with complications, and the rates of clinical and procedural success are lower in this group. Long-term survival after a TLE is similar in patients with MLVSO and those without venous obstruction. MLVSO probably better depicts the severity of global venous obstruction than the degree of vein narrowing at only one point.

Pacemaker leads as a potential source of problems in patients who might need a central venous access port

Background

Lead-dependent venous occlusion may impede the insertion of a central venous access device (CVAD). The aim of this retrospective, cohort study was to assess the chance of implantation of CVAD in patients with cardiac implantable electronic devices (CIEDs).

Methods

We reviewed and analyzed 3,075 venograms of patients with CIEDs undergoing transvenous lead extraction (TLE) between June 2008 and July 2021. Relationship between venous patency and the chance of CVAD placement was estimated.

Results

In 2,318 (75.38%) patients, venography showed no potential obstacles to venous port implantation on the ipsilateral side. In patients with leads on the left side, significant narrowing more often affected the subclavian vein than the brachiocephalic vein [1,595 (55.29%) vs. 830 (28.63%), respectively] or the superior vena cava (SVC) [21 (0.73%) cases]. Furthermore, the subclavian and brachiocephalic veins on the opposite side were also narrowed [35 (2.35%) and 27 (1.24%), respectively]. The chances of port insertion were assessed as easy on CIED side or opposite side in 2,318 (75.38%) and 2,291 (97.91%) patients, respectively), as difficult insertion/questionable performance in 246 (8.00%) and 22 (0.94% patients) and doubtful or impossible insertion/questionable performance in 511 (16.62%)/27 (1.15%) patients with CIED.

Conclusions

(I) Varying degrees of lead-dependent venous obstruction (LDVO) is a frequent finding in patients with CIEDs; (II) the major thoracic veins on the opposite side of the chest may also be significantly narrowed; (III) venography should be considered before attempted CVAD insertion in patients with long lead dwell times or in patients after CIED removal, including planned contralateral port placement.

Superior vena cava obstruction and cardiovascular implantable electronic devices-a new era of leadless devices

Cardiovascular implantable electronic devices (CIEDs) such as pacemakers and implantable cardioverter defibrillators require the placement of a transvenous lead through the superior vena cava (SVC), which can be difficult if there is stenosis or obstruction of the SVC. Moreover, SVC syndrome may occur after the lead is inserted even if the SVC was intact before the implantation. Therefore, there is need of an appropriate strategy for handling stenosis or obstruction of SVC during lead placement. In addition, advances are being made in CIEDs that do not require transvenous leads, and thus CIEDs without a transvenous lead should be considered depending on the indications and urgency of the particular case. This manuscript is divided into (I) device therapy for patients with SVC obstruction and (II) therapeutic strategy for SVC obstruction after lead implantation. In patients with SVC syndrome, treatment of the SVC occlusion should be based on the individual pathophysiology, and depending on the indications and urgency of the case, treatment with CIEDs that do not require transvenous leads should be considered. Further data must be accumulated to clarify the long-term prognosis of device implantation after treatment of SVC occlusion. In addition, transvenous lead extraction is now widely used for device-related SVC obstruction, and this procedure also merits further accumulation of data.

Transvenous lead extraction, factors affecting procedural difficulty

BACKGROUND

A complex transvenous lead extraction (TLE) procedure could be associated with lower success and higher complication rates in inexperienced hands. In this study, we aim to assess the factors that determine procedural difficulty in TLE.

METHODS

We retrospectively studied 200 consecutive patients undergoing TLE in a single referral centre from June 2020 to December 2021. Lead extraction difficulty was assessed by the success of simple manual traction with or without a locking stylet, the need for advanced extraction tools and the number of tools required to extract the lead. Logistic and linear regression analyses were used to determine the factors independently affecting these 3 parameters.

RESULTS

363 leads were extracted from 200 patients (79% males, mean age 66.85 years). The indication for TLE was device-related infection in 51.5%. Multivariate analysis revealed the lead indwelling time to be the only factor affecting the 3 parameters of difficulty. Passive fixation leads and dual coil leads increased procedural difficulty by affecting 2 parameters each. Factors that affected one parameter included infected leads, coronary sinus leads, older age of the patient and a history of valvular heart disease, all associated with a simpler procedure. Right ventricular leads were associated with a more complex one.

CONCLUSION

The most important factor that increased TLE procedural difficulty was a longer lead indwelling time, followed by passive fixation and dual-coil leads. Other contributing factors were the presence of infection, coronary sinus leads, older patients, a history of valvular heart disease and right ventricular leads.

How does a CIED presence influence chances and safety of haemodialysis access? Conclusions from over 3000 thoracic venografies

Patients requiring temporal or permanent catheter or arterio-venous fistula (AVF) for haemodialysis may be in challenging situation, if they are cardiovascular implantable electronic devices (CIED) carriers.

MATERIALS AND METHODS

The authors analysed preoperative venogrphies of 3100 patients referred for transvenous lead extraction for a possible chance of safe haemodialysis catheter (HC) implantation or proper AVF function.

RESULTS

A chance of safe catheter implantation parallel to existing leads reaches 68.8% ipsilaterally to CIED. Contraindications for implantation have been found in less than 2% of cases contralaterally. Ipsilaterally proper AVF function chance has been found in 50.3% of the cases and almost 98% contralaterally. A bilateral chest electrodes location require the special attention. Abandoned lead, lead burden, bilateral leads, additional lead implantation or abandonment, and implant duration may have a significant influence on HC insertion or proper function of arteriovenous fistula.

CONCLUSION

(1) Obstruction of prominent thoracic veins is a frequent finding in CIED carriers and may impede or disable implantation haemodialysis accesses. (2) Implantation of temporary or permanent HC may be questionable ipsilaterally to the CIED in 31.2% and contralaterally in 2.0% of patients. Proper function of AVF is uncertain in 49.7% ipsilaterally and 2.1% contralaterally to CIED. (3) Pacing history and leads dwell time influence chances of success haemodialysis access even on the free-from CIED chest side. (4) Proper venous flow evaluation seems to be valuable in CIED carriers before an attempt of haemodialysis access formation, even contralaterally.

Practical Approaches to Transvenous Lead Extraction Procedures-Clinical Case Series

Transvenous lead extraction (TLE) is regarded as the first-line strategy for the management of complications associated with cardiac implantable electronic devices (CIEDs), when lead removal is mandatory. The decision to perform a lead extraction should take into consideration not only the strength of the clinical indication for the procedure but also many other factors such as risks versus benefits, extractor and team experience, and even patient preference. TLE is a procedure with a possible high risk of complications. In this paper, we present three clinical cases of patients who presented different indications of TLE and explain how the procedures were successfully performed. In the first clinical case, TLE was necessary because of device extravasation and suspicion of CIED pocket infection. In the second clinical case, TLE was necessary because occlusion of the left subclavian vein was found when an upgrade to cardiac resynchronization therapy was performed. In the last clinical case, TLE was necessary in order to remove magnetic resonance (MR) non-conditional leads, so the patient could undergo an MRI examination for the management of a brain tumor.

Efficacy and Safety of Transvenous Lead Extraction at the Time of Upgrade from Pacemakers to Cardioverter-Defibrillators and Cardiac Resynchronization Therapy

BACKGROUND

Upgrading from pacemakers to ICDs and CRTs is a difficult procedure, and often, transvenous lead extraction (TLE) is necessary for venous access. TLE is considered riskier in patients with multiple diseases. We aimed to assess the complexity, risk, and outcome of TLE among CRT and ICD candidates.

METHODS

We analyzed clinical data from 2408 patients undergoing TLE between 2006 and 2021. There were 138 patients upgraded to CRT-D, 33 patients upgraded to CRT-P and 89 individuals upgraded to ICD versus 2148 patients undergoing TLE for other non-infectious indications.

RESULTS

The need for an upgrade was the leading indication for TLE in only 36-66% of patients. In 42.0-57.6% of patients, the upgrade procedure could be successfully done only after reestablishing access to the occluded vein. All leads were extracted in 68.1-76.4% of patients, functional leads were retained in 20.2-31.9%, non-functional leads were left in place in 0.0-1.1%, and non-functional superfluous leads were extracted in 3.6-8.4%. The long-term survival rate of patients in the CRT-upgrade group was lower (63.8%) than in the non-upgrade group (75.2%).

CONCLUSIONS

Upgrading a patient from an existing pacemaker to an ICD/CRT is feasible in 100% of cases, provided that TLE is performed for venous access. Major complications of TLE at the time of device upgrade are rare and, if present do not result in death.

Repeat Transvenous Lead Extraction-Predictors, Effectiveness, Complications and Long-Term Prognostic Significance

BACKGROUND

Data regarding repeat transvenous lead extraction (TLE) are scarce. The aim of study was to explore the frequency of repeat TLE, its safety, predisposing factors, as well as effectiveness of repeat procedures.

METHODS

Retrospective analysis of a large single-center database of 3654 TLEs.

RESULTS

Repeat TLE was a rare occurrence (193, i.e., 5,28% among 3654 TLEs). Subsequent re-extractions occurred in 12.21% of the patients. Lead failure was the most common cause of re-extraction (51.16%). Cox regression analysis showed that patients who were older at first implantation [HR = 0.987; p = 0.003], had infection-related TLE [HR = 0.392; p < 0.001] and complete procedural success [HR = 0.544; p = 0.034] were less likely to undergo repeat TLE. Functional leads left in place for continuous use [HR = 1.405; p = 0.012] or superfluous leads left in place (abandoned) [HR = 2.370; p = 0.011] were associated with an increased risk of undergoing a repeat procedure. Overall mortality in patients with repeat TLE and subsequent re-extraction in the entire FU period was similar to that in patients without a history of re-extraction [HR = 0.949; p = 0.480].

CONCLUSIONS

Repeat TLE was a rare occurrence (5.28%) among TLEs. Left of both active and nonactive leads during TLE increased the risk of re-extraction. Re-extraction has no effect on the long-term mortality.

Severity and Extent of Lead-Related Venous Obstruction in More Than 3000 Patients Undergoing Transvenous Lead Extraction

Background

Lead-related venous stenosis/obstruction (LRVSO) may be a major challenge in patients with cardiac implantable electronic devices (CIED) when device upgrade, insertion of central lines, or creation of an arteriovenous fistula for hemodialysis is indicated. The aim of this study was to evaluate the extent and severity of LRVSO.

Methods

We performed a retrospective analysis of 3002 venograms from patients awaiting transvenous lead extraction (TLE) to assess the occurrence, severity, and extent of LRVSO.

Results

Mild LRVSO occurred in 19.9%, moderate in 20.7%, severe in 19.9% and total venous occlusion in 22.5% of the patients. Moderate/severe stenosis or total occlusion of the subclavian and brachiocephalic veins was found in 38.2% and 22.5% of the patients, respectively. LRSVO was not detected in 16.9% of the patients. Moderate and severe superior vena cava (SVC) obstruction and total SVC occlusion were rare (0.4%, 0.3%, and 0.3%, respectively). Lead insertion on the left side of the chest contributed to an increased risk of LRVSO compared to right-sided implantation. Major thoracic veins on the opposite side may be narrowed in varying degrees.

Conclusion

A total of 60% of the patients with pacemaker or high-voltage leads have an advanced form of LRVSO. Any attempt to insert new pacing leads, central lines, venous ports, or catheters for hemodialysis, or to create dialysis fistula on the same side as the existing lead should be preceded by venography. Furthermore, venography may provide useful information, if it is planned to implant the lead or the catheter on the opposite side of the chest.

Looking for Lead Adhesions While Planning for Transvenous Lead Extraction

The first implantable pacemaker was placed in the 1958, ushering in a new frontier of cardiovascular medicine. This article is protected by copyright. All rights reserved.

New Insights in Central Venous Disorders. The Role of Transvenous Lead Extractions

Over the last decades, the implementation of new technology in cardiac pacemakers and defibrillators as well as the increasing life expectancy have been associated with a higher incidence of transvenous lead complications over time. Variable degrees of venous stenosis at the level of the subclavian vein, the innominate trunk and the superior vena cava are reported in up to 50% of implanted patients. Importantly, the number of implanted leads seems to be the main risk factor for such complications. Extraction of abandoned or dysfunctional leads is a potential solution to overcome venous stenosis in case of device upgrades requiring additional leads, but also, in addition to venous angioplasty and stenting, to reduce symptoms related to the venous stenosis itself, i.e., the superior vena cava syndrome. This review explores the role of transvenous lead extraction procedures as therapeutical option in case of central venous disorders related to transvenous cardiac leads. We also describe the different extraction techniques available and other clinical indications for lead extractions such as lead infections. Finally, we discuss the alternative therapeutic options for cardiac stimulation or defibrillation in case of chronic venous occlusions that preclude the implant of conventional transvenous cardiac devices.