Ancillary Tools in Pacemaker and Defibrillator Lead Extraction Using a Novel Lead Removal System

Abstract

A previous report described our preliminary experience with a highly successful pacing lead removal system (VasoExtor). Extending this experience, we found it necessary to use additional tools to enhance the success of percutaneous lead extraction with this system. In the present series, we used the standard locking stylets (S and K), and recently, one newer type of stylet (Magic) over the last 3 years in 34 patients to extract 48 pacemaker leads in 31 patients and 3 defibrillator (ICD) leads in 3 patients. Lead extraction was carried out in 23 men and 11 women (aged 64 +/- 17 years) because of pacemaker infection (n = 21), pacemaker (n = 8) or ICD (n = 3) lead malfunction, or prior to ICD implant (n = 2). Leads were in place for 3.5 +/- 3.7 years. Infections, involving pocket and lead(s), were due to S. epidermidis (n = 13), S. aureus (n = 6), S. aureus plus E. coli (n = 1), for fungi (n = 1). Of the 48 pacing leads, 31 were ventricular, 15 atrial, and 2 were VDD leads. The ICD leads were two double-coil leads (CPI) and one single-coil lead (Telectronics). Using the S (n = 12), K (n = 8), or Magic (n = 3) stylets, all pacing leads in 23 patients and the ICD leads in 2 patients were successfully removed from a subclavian approach using the locking stylets. However, in nine (26.5%) patients ancillary tools were required. In four patients, lead fragments were captured with use of a noose catheter, a pigtail catheter, and a bioptome from a right femoral approach. In two patients, locking could not be effected and a noose catheter from the right femoral vein was used, aided by a pigtail and an Amplatz catheter and a bioptome to remove three leads. In a patient with an ICD lead, a combined subclavian (stylet S) and right femoral approach (noose catheter) was required. In a patient with a dysfunctional ventricular lead 12 years old, a motor drive unit was used to facilitate the exchange of locking stylets, but extraction failed. In another patient, a fragment of a dysfunctional ventricular lead remained intravascularly despite resorting to a femoral approach. Finally, lead removal was completely (32/34, 94%) or partially (1/34, 3%) successful in 33 (97%) of 34 patients for 50 (98%) of 51 leads without complications. In conclusion, to enhance the success of pacing or ICD lead extraction with use of the VascoExtor locking stylets, an array of ancillary tools were required in more than one fourth of patients.

Nonthoracotomy Implantable Defibrillator Lead Extraction:

“…Previous studies have addressed the issue of NTL extraction 11–14 , 19–22 . Costa et al 15 recently described their experience using LASER for extraction of 56 relatively long‐standing pacemaker and NTLs (mean implantation time 7.5 years), 9 of which were ICD leads.…”

ICD Leads:

“…Initially until the mid‐1990s, an extraction rate of only 80% of all pacemaker and ICD leads was attained using special extraction guidewires and locking stylets 36 . In 1998, the introduction of the laser extraction systems and further ancillary tools (additional femoral approach using lasso and pigtail catheters and bioptomes) allowed complete lead removal in 90–95% of cases and partial lead removal in up to 97% of all leads 37–39 . At the same time, the risk of severe complications including pericardial tamponade mandating emergency thoracotomy and death decreased from 8.1% to 4.1% 38 .…”

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

“…In all of these studies most leads were pacemaker leads. The proportion of ICD leads only was 6% to 18% in these studies 14–19 . The study with the largest number (n = 138) of extracted ICD leads showed an overall complication rate of 7% 20 .…”

“…The success rate of lead extraction has significantly improved and the risk has diminished over the last 5 to 10 years. 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 .…”

“…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 .…”