Background - Clinical factors associated with development of intravascular lead adherence (ILA) are unreliable predictors. Because vascular injury in the superior vena cava - right atrium (SVC-RA) during transvenous lead extraction (TLE) is more likely to occur in segments with higher degrees of ILA, reliable and accurate assessment of ILA is warranted. We hypothesized that intravascular ultrasound (IVUS) could accurately visualize and quantify ILA and degree of ILA correlates with TLE difficulty. Methods - Serial imaging of leads occurred prior to TLE using IVUS. ILA areas were classified as high or low grade. Degree of extraction difficulty was assessed using 2 metrics and correlated with ILA grade. Lead extraction difficulty (LED) was calculated for each patient and compared to IVUS findings. Results - 158 vascular segments in 60 patients were analyzed: 141 (89%) low grade versus 17 (11%) high grade. Median extraction time (low=0 versus high grade=97 seconds, p<0.001) and median laser pulsations delivered (low=0 versus high grade=5852, p<0.001) were significantly higher in high grade segments. Most patients with low LED score had low ILA grades. 86% of patients with high LED score had low IVUS grade and the degree of TLE difficulty was similar to patients with low IVUS grades and LED scores. Conclusions - IVUS is a feasible imaging modality that may be useful in characterizing ILA in the SVC-RA region. An ILA grading system using imaging correlates with extraction difficulty. Most patients with clinical factors associated with higher extraction difficulty may exhibit lower ILA and extraction difficulty based on IVUS imaging.

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Stress-only upright and supine CZT imaging was non-inferior statistically to attenuation-corrected stress-only Anger camera imaging. Nevertheless, stress-only CZT imaging may be associated with reduced diagnostic sensitivity for some readers compared to attenuation-corrected Anger camera images, which may be less acceptable clinically compared to stress plus rest images.

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