Excimer Laser for Pacemaker and Defibrillator Lead Extraction: Techniques and Clinical Results

Abstract

Pacing and defibrillation leads may need to be removed for several reasons including infection, interference with others leads, lack of vascular access or redundancy. However, the removal of chronically implanted leads is a major technical challenge because of the extensive adhesions that develop along the course of the leads over time. The techniques to remove chronic leads have been greatly facilitated by the development of an excimer laser sheath. We undertook an analysis of our experience with laser extraction in the first 50 leads attempted. An excimer laser sheath system, developed by the Spectranetics Corporation, was used to extract 50 chronically implanted leads in 34 patients. The mean patient age was 64+/-12 years, all were male and the average duration that the leads had been implanted was 5.0+/-3.9 years. Two-thirds of the leads were pacemaker and one-third were defibrillator leads. There was a 100% clinical success rate and 48 of the 50 leads were completely removed. There were no major complications. There was one minor complication of subclavian vein thrombosis and two haemodynamically non-significant episodes of air embolism. The main limitation observed was failure of the excimer laser sheath to advance in 18% of cases, probably due to the presence of calcified adherences on leads. Two strategies were found useful to deal with this problem: under the clavicle stainless-steel sheaths were used to break up calcified adherences and within the venous system the laser sheath was upsized in order to advance over the calcification on the lead. It was concluded that excimer laser has greatly facilitated the removal of chronically implanted pacemaker and defibrillator leads. There is a high success rate and low complication rate in our experience. The main limitation of laser is the presence of calcified adherences.

Laser Lead Extraction in Congenital Heart Disease: A Case‐Controlled Study

“…Calcium was observed along the trajectory of these two leads, leading the authors to suggest that the LLE failures were related to calcified adhesions. Gilligan and Dan report difficulty in advancing the laser sheath over nine of 50 leads (18%) and likewise postulated that lead calcifications factored into this difficulty . The problem of calcified adhesions was ameliorated in their study by advancing a stainless‐steel sheath over the lead or by upsizing the laser sheath, and the authors reported a 96% complete extraction success rate and only one minor complication (venous occlusion with arm swelling) using those techniques.…”

Laser Lead Extraction: Predictors of Success and Complications

“…Success and complication rates reflect this particular approach, which did not consider alternative extraction technologies such as electrosurgical (radiofrequency) sheaths. Several series have previously described procedural efficacy and complication rates associated with laser extraction of pacemaker and defibrillator leads 3–8 . The “Pacing Lead Extraction with the eXcimer Sheath” (PLEXES) trial 6 compared laser lead extraction with Teflon telescoping sheaths in 301 patients.…”

“…All laser lead extractions were performed with the Spectranectics laser sheath removal system (Colorado Springs, Colorado, CO, USA). The extraction technique has been previously detailed 3–6,8,9 . All procedures were performed in the operating room under general anesthesia by the same cardiac surgeon (PP).…”

“…Manual traction is often effective to remove leads implanted no more than a few months prior. However, more chronic leads characteristically develop fibrous attachments to surrounding structures and require more advanced extraction systems 2, 3 …”

Excimer laser ablation for valvular angioplasty in pulmonary atresia and intact ventricular septum

“…Those include revascularization of coronary and saphenous venous grafts by plaque debulking and thrombus removal in acute coronary syndromes, including acute myocardial infarction and unstable angina. This laser is applied as well for revascularization of peripheral obstructive atherosclerotic disease and for debulking of fibrotic tissue surrounding old pacemaker electrodes or internal defibrillator leads that need to be explanted [44].…”