Lead Extraction

Lead removal, also called lead extraction. In certain situations, it may be necessary to remove the leads that are in place in your vessels and your heart. The extraction can be performed during open heart surgery (surgical lead extraction) or, more commonly, via the veins in which the leads have been introduced (transvenous lead extraction). The reason for extraction may be:

• a lead is no longer useful (in this situation, the lead can be left in place but, sometimes, to limit the number of leads in your body, your doctor may decide to remove a lead that is no longer useful)
• a lead it is not working or has been replaced by another one
• your device becomes infected. It is important to understand that, even if the infection seems to affect only the pacemaker or defibrillator generator, only the removal of the entire system (can and leads), combined with treatment with antibiotics, can guarantee a cure.

 

In this case, you will probably be referred to a centre with particular expertise in lead extraction. This expertise will involve a multidisciplinary team including a cardiac pacemaker or defibrillation specialist with extraction expertise, as well as cardiac surgeons, anaesthesiologists and possibly infection specialists.

 

Transvenous Lead Extraction

Transvenous lead extraction is the most common approach. It must be carried out in a highly secure environment in the immediate vicinity of, or inside, a cardiac surgery operating theatre. The procedure involves:

• reopening the pacemaker or defibrillator pocket,
• disconnecting the leads and
• freeing any adherences that may exist at any point along the lead route between entry into a vein and attachment to the myocardium. The lead is then pulled out of the veins by gentle traction

 

To do this, the physician will need specific equipment that varies from one physician to another:

• Passive sheaths, i.e., sheaths introduced from the device pocket, over the lead and that require manual manipulation (gentle rotation and advancement) by the physician to free the lead;
• Rotating dissection sheaths, i.e., sheaths introduced from the device pocket, over the lead and equipped with rotating bladders
• Active dissection sheaths, i.e. sheaths introduced from the device pocket, over the lead, that use energy (usually laser excimer) to free the lead from adherences
• Snares in order to grasp the lead from a femoral vein access (from the groin); they may be useful sometimes, as a complement to the sheaths

 

Surgical extraction

Surgical extraction is an open-heart surgery during which the surgeon removes the leads from the heart by a direct approach and dissection, and the can from the pocket. It is rarely proposed nowadays unless there is a contra-indication to transvenous lead extraction, or the patient is operated for another reason.

Overall, catheter extraction is a meticulous procedure which, when carried out by trained teams, has a very high success rate (over 95%) and a complication rate of around 7%, some of which can be very serious (in about 2% of cases). You can ask your doctor any questions you may have.

After extraction, a decision will be made as to whether or not a new pacemaker or ICD needs to be re-implanted and what type of material will be used.