Strategies for Transvenous Lead Extraction Procedures

Abstract

ABSTRACT. Transvenous lead extraction (TLE) has undergone an explosive evolution since its inception as a rudimentary skill with limited technology and therapeutic options. Early techniques involved simple manual traction that frequently proved ineffective for chronically implanted leads, and carried a significant risk of myocardial avulsion, tamponade, and death. The morbidity and mortality associated with these early extraction techniques limited their application to use only in life-threatening situations, such as infection and sepsis. The past four decades, however, have witnessed significant advances in lead extraction technology, resulting in more efficacious techniques and tools, providing the skilled extractor with a well-equipped armamentarium. With the development of the discipline, we have witnessed a growth in the community of TLE experts coincident with a marked decline in the incidence of procedure-related morbidity and mortality, with recent registries at high-volume centers reporting high success rates with exceedingly low complication rates. Future developments in lead extraction are likely to focus on new tools that will allow for us to provide comprehensive device management, develop alternative systems for extraction training, and focus on the design of new leads conceived to facilitate future extraction.

Powered sheaths for lead extraction

“…Simple traction may be useful for short dwell time leads. 14 Locking stylets are conceived to facilitate traction by reinforcement to the tip and stabilization of the lead, reducing the risk of disruption and increasing the removal odd 15,16 ; they may be engaged alone or combined with other tools. 10 Several types are available, differing in their locking mechanism (placed at the distal tip rather than secured at multiple lead sites).…”

“…They might be employed alone, applying countertraction, or with facilitating handles, commonly with a locking stylet. Using non powered sheaths, TLE success rate via an implant vein approach has remarkable rates of safety and success that, starting from the 71% of initial experiences, 15,17,19 reaches nowadays 95.0% and 96.5-97.9% of complete and clinical success, respectively 20 Centers performing TLE without powered sheaths generally use a strategy based on mechanical dilatation performed through the venous entry-site and, if necessary, on crossover to the internal transjugular approach. In a recent experience from Bongiorni and coworkers, 21 shifting to transjugular approach when needed, increased the success rate from 89% to 99%, and a dwell time of 55 months best-predicted crossover to the internal transjugular approach.…”

“…The mechanism through which dissection is obtained are essentially three: (a) photochemical, to disrupt molecular bonds; (b) photothermal, to vaporize intracellular water provoking cellular rupture; (c) photomechanical, which means that expansion and collapse of vapor bubble break down tissue and clears by-products away from the tip (Figure 5). Through the standard techniques of counterpressure and countertraction the sheath is advanced over the lead and energy is released when encapsulating tissue blocks sheath advancement 15 ;…”

Modern approaches to transvenous lead extraction

“…Ранние методики удаления представляли собой простую тракцию (рис. 1), которая часто оказывалась неэффективной в первую очередь для длительно находящихся имплантируемых электродов и сопровождалась очень высоким риском осложнений -перфорация миокарда, тампонада сердца, смерть, что в свою очередь ограничивало ее широкое внедрение в хирургию, и применялась только в сочетании с хирургией на открытом сердце в угрожающих для жизни ситуациях, таких как инфекция и сепсис [1,2]. За последние сорок лет достигнут прорыв в области методики удаления электродов (рис.…”

“…В выборе решения о ТЭЭ мы поддерживаем мнение ряда авторов Silvetti MS, Drago F и Epstein LM, Maytin M, что, несмотря на отсутствие рандомизиро-ванных контролируемых исследований по экстракции в сравнении с оставленными (не удаленными) электродами, но имеющимися доказательными данными когортных регистрационных исследований подтверждают утверждение: "что потенциальная будущая выгода от удаления электрода перевешивает риски отказа от удаления электрода, и что данный отказ следует рассматривать, как "паллиативную процедуру", которая просто откладывает неизбежное удаление электрода в будущем" [1,12].…”