Similar Indications but Different Methods: Should There Be a Consensus on Optimal Lead Extraction Techniques?

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.

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Laser Lead Extraction: Is There a Learning Curve?

Ghosh

Yee

Klein

et al. 2005

“…Therefore, a stepwise approach appears logical beginning with gentle simple traction without destroying the inner lumen followed by increased traction on a locking stylet, and then the laser sheath. The femoral approach should be used after superior approaches have failed 43 …”

Section: Lead Extractionmentioning

confidence: 99%

ICD Leads:

Gradaus

Breithardt

Böcker

2003

The treatment of ventricular tachyarrhythmias has changed over the last 10 years. Implantable cardioverter defibrillators (ICDs), once used only as a last resort therapy, have now become the treatment of choice. This change occurred before the first results of randomized studies on ICD therapy in patients with life-threatening ventricular tachyarrhythmias were published by the end of 1997. Technological advances of ICD therapy, in particular the development of transvenous leads, were to a large extent responsible for this change. Modern leads are characterized by their multilumen design that incorporates straight wires and coiled conductors into a single electrode body. Conductors and insulation are sheathed with additional insulation layers. The most frequently used insulating materials are silicone, polyurethane, and fluoropolymers. Lead failures are an important complication of ICD therapy. Fractured conductors, compression, creeping, or insulation defects from abrasion can cause such lead dysfunctions. Chronically implanted leads will inevitably have an increased risk of failure due to defects despite all technological advances. In the light of improving survival figures in patients with ventricular tachyarrhythmias and increasing numbers of ICD implantations, lead failures are becoming a clinical problem of ever increasing importance. Therefore, the question of which lead types necessitate extraction when a certain failure occurs and which leads can be left in place. Despite continuous improvements in lead extraction systems and growing experience in their use, the extraction of any pacemaker or ICD lead is associated with some risk of complications.

“…The incidence is reported only anecdotally. In the majority of the published cases, the catheter is entrapped in either the superior caval vein or the right atrium during surgical procedures requiring bicaval cannulation 3 . In all cases, the catheter was removed after resternotomy and after the removal of the entrapping suture 4,5 …”

Section: Discussionmentioning

confidence: 99%

Transvenous Removal of an Entangled Central Venous Line Following Complex Cardiac Surgery

Ke¹,

Aebert²,

Stock³

et al. 2009

Unintended internal suturing of central venous lines or pulmonary artery catheters in the superior caval vein or the right atrium following cardiac surgery remains a rare but troublesome complication. The line is normally entangled in safety or hemostasis sutures after the removal of the superior caval cannulation. If mild tension is unsuccessful, the patient normally undergoes resternotomy. The objective of this brief communication is to describe of a simple and safe removal method using a transvenous rotational cutting device to divide the hemostasis suture. In order to avoid complicating bleeding, a time delay between initial placement and removal is highly recommended. For extraction, a fully equipped cardiovascular operating room with central venous and arterial lines, attached defibrillator pads, transesophageal echo monitoring, fluoroscopy, and a surgical team, including a heart and lung machine and a perfusionist standby, is mandatory.