Characterization of Lead Adherence Using Intravascular Ultrasound to Assess Difficulty of Transvenous Lead Extraction

Abstract

<jats:p> <jats:bold>Background</jats:bold> - 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. </jats:p> <jats:p> <jats:bold>Methods</jats:bold> - 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. </jats:p> <jats:p> <jats:bold>Results</jats:bold> - 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&lt;0.001) and median laser pulsations delivered (low=0 versus high grade=5852, p&lt;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. </jats:p> <jats:p> <jats:bold>Conclusions</jats:bold> - 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. </jats:p>

Utility of fluoroscopy alone for monitoring of intrathoracic bleeding complications during transvenous lead extraction

“…It is important to note that presently there is an increasing trend to utilize intraprocedural echocardiographic imaging not only for detection of procedural complications but also for risk stratification during TLE procedures. Several studies evaluated the utility of intraprocedural ICE and intravascular ultrasound for real‐time visualization of the intravascular lead course and adherence during TLE procedures 5,11 . However, while some high‐risk features on those imaging modalities were shown to help identify a subset of patients whose extractions might be more difficult and complex, correlation with procedural success and safety has been lacking 5,11 .…”

“…Several studies evaluated the utility of intraprocedural ICE and intravascular ultrasound for real-time visualization of the intravascular lead course and adherence during TLE procedures. 5,11 However, while some high-risk features on those imaging modalities were shown to help identify a subset of patients whose extractions might be more difficult and complex, correlation with procedural success and safety has been lacking. 5,11 This is consistent with the results of our study, whereby the lack of echocardiographic information regarding lead adherence did not appear to adversely influence the TLE procedural outcome, given the high success and low complication rates in our cohort.…”

Looking for Lead Adhesions While Planning for Transvenous Lead Extraction

“…3 Other studies utilizing IVUS and ICE have also reported an association between lead adherence and increased TLE complexity. 4,5 Interestingly, Beaser et al reported that the finding of minimal adhesions by intravascular ultrasound were associated with lower complexity during TLE even in the setting of other clinical factors which typically predict higher complexity such as lead dwell time, presence of multiple leads and the presence of an SVC coil. 4 In fact, even adhesions in the pocket have been associated with increased TLE complexity and the need for a higher number of extraction tools.…”

“…4,5 Interestingly, Beaser et al reported that the finding of minimal adhesions by intravascular ultrasound were associated with lower complexity during TLE even in the setting of other clinical factors which typically predict higher complexity such as lead dwell time, presence of multiple leads and the presence of an SVC coil. 4 In fact, even adhesions in the pocket have been associated with increased TLE complexity and the need for a higher number of extraction tools. 8 While Aboelhassan et al found an association between lead-venous adherence and procedure complexity, there was no such association in patients with venous occlusion.…”

“…Using IVUS, Beaser et al reported high grade adherence in 25% of patients. 4 Sadek et al used ICE to look for lead binding to the SVC or myocardium and detected significant binding in 36% of patients. 5 While, the modalities differ in how they detect these adhesions and, to some degree, the structures being assessed, together, the studies tell us that adhesions binding leads to other structures is common.…”