With increasing numbers and complexity of implantable devices, the need for lead extraction is also increasing. There is little UK data available on clinical outcomes. We compiled a multi-centre registry of patients undergoing lead extraction to investigate predictors of success and complications.Methods
Data on all cases at three UK tertiary centres (St. Barts and The Heart Hospital London and Papworth Hospital Cambridge) were collected over 18 months. Cases where leads were >1 year in age or where specialist extraction equipment was used were included (cases=137, leads=268).Results
69% of patients were male, age 66±16 years (mean±SD). Devices extracted were single chamber PPMs (5%), dual chamber PPMs (42%), CRTPs (6%), single chamber ICDs (6%), dual chamber ICDs (17%) and CRTDs (24%). 76% of ICD leads were dual coil. Number of leads extracted per patient was 2.0±1.0 and time from implantation was 8.3±11.1 years. Leads were extracted using simple traction (39%), traction with locking stylets alone (8%) or dilator sheaths (5%), bidirectional cutting sheaths (38%) or laser (10%). Only 2% of cases required additional femoral access. Specialist equipment was preferentially used for older leads (10.4±13.1 vs 5.2±5.8 years, p<0.001) and for ICD leads (84% vs 53%, p<0.001).Results
The rate of major procedural adverse events (AE) leading to death or emergent surgery was 2.2%, major AEs unrelated to the procedure was 5.8% and minor AEs was 8.7%. Predictors of AEs include patient age (77±28 vs 66±15 years, p=0.05), the age but not type or number of lead (14.8±24.5 vs 7.2±6.0 years, p=0.01), systemic infectiona(31 vs 8%, p<0.001), increased creatinine level (142±111 vs 108±23 µmol/L, p=0.011), decreased haemoglobin level (109±23 vs 123±24 g/L, p=0.001) and use of assisted traction or laser over simple traction or mechanical cutting sheathsb (p=0.001) – see Table. Complete extraction was achieved in 95.5% of leads, with only 2.2% with >4 cm of lead remaining in situ. Predictors of procedural failure include age but not type or number of leads (11.1±8.6 vs 8.3±11.3 years, p=0.05), systemic infectionc(24 vs 3%, p<0.001) and increased creatinine (162±126 vs 108±66 µmol/L, p=0.012). Laser extraction resulted in 100% success in removing leads. Gender, procedure duration, fluoroscopy time and dose, use of general anaesthesia or temporary pacing was independent of extraction technique and outcome.Discussion
This is the first UK prospective multi-centre study of lead extraction data comparing extraction techniques. Overall there is a low major complication and high success rate with the use of either simple traction or specialist equipment. From our findings, high risk cases can be identified pre-procedure to allow adequate case planning. Laser extraction is clinically effective but is associated with a higher complication rates compared with mechanical cutting sheaths.