Laser Lead Extraction: Is There a Learning Curve?

Abstract

Laser extraction of device leads offers an attractive alternative to countertraction and electrosurgical dissection sheath, potentially increasing efficacy and reducing complications. Wider adoption of this technology depends on relative ease of use. We report the experience of a new center to define the "learning curve." We performed 76 laser lead extractions in 75 patients (age 63 +/- 17 years, 59 male) from July 2001 to January 2004. Two experienced device implanters who were novice extractors underwent a 2-day site visit to a high volume extraction center for training. Lead extractions were performed in the operating room with immediate surgical backup. The indication for extraction was infection in 39 (systemic in 15), erosion or pain in 11, and lead related or debulking in 25. Complete removal was achieved in 139 of 145 leads (14 ICD, 131 pacemaker). Partial removal (<4 cm retained) was achieved in five leads (4%), and one lead could not be extracted. Complete success was 95% in the first third of patients, 94% in the second third, and 100% in the latter third. Fluoroscopy time fell from 19 +/- 22 minute in the first third of patients to 11 +/- 8 minute in the second third to 8 +/- 4 minute in the latter third (ANOVA P = 0.02). No major complications occurred. Local bleeding required minor left subclavian vein repair in two individuals. Symptomatic venous thrombosis occurred in 3 of the first 11 cases 1-21 days after extraction, but did not occur in the next 64 consecutive patients who received a 1-month anticoagulation regimen (27% vs 0%, P < 0.001). One patient developed venous thrombosis 3 weeks following cessation of warfarin therapy. Practice guidelines reasonably recommend appropriate training prior to independent performance of lead extraction. The current study suggests that experienced device implanters with appropriate operative backup taking a limited, but intensive training program can be safe and effective at lead extraction in a short time, in part a reflection of the improved technology.

Virtual Reality Lead Extraction as a Method for Training New Physicians: A Pilot Study

“…TLE requires an expertise that can only be gained through adequate training and repeated practice. Several studies have repeatedly demonstrated the direct relationship between case volume and both procedural success and complications . In fact, procedural success improves after the first 10 cases and requires continued practice to maintain complete procedural success rates .…”

Management of infections involving implanted cardiac electrophysiologic devices

“…Similar reports of successful percutaneous extraction of large vegetations appear in the literature [ 22 , 25 , 26 ]. Although these trials described all possible complications related to lead extraction, our own limited experience supports a lower complication rate with the laser technique [ 27 ]. • Lead extraction provides the best results, but lifelong suppressive antibiotic therapy is an alternative for patients with signifi cant comorbidities who are unlikely to survive surgery.…”

Two Different Therapeutic Strategies in ICD Lead Defects: Additional Combined LeadVersus Replacement of the Lead

“…The introduction of laser extraction systems and further ancillary tools has allowed complete lead removal in 89% to 97% of cases 14–20 . At the same time, the risk of severe complications decreased from 8.1% to 3.3% 14–17,19–21 . However, lead extraction has been associated with mortality between 1% and 2% 14–17 .…”