Transvenous Removal of Pacing and Implantable Cardiac Defibrillating Leads using Single Sheath Mechanical Dilatation and Multiple Venous Approaches

Introduction Device related complications are raising the need for transvenous lead removal (TLR). Transvenous extraction of pacing (PL) and defibrillating leads (DL) is a highly effective technique. The aim of this chapter is to describe an 18 year single-center experience in pacing and defibrillating leads removal using an effective and safe modified mechanical dilatation technique. Methods We developed a single mechanical dilating sheath extraction technique with multiple venous entry site approaches. We performed a venous entry site approach (VEA) in cases of exposed leads, and an alternative transvenous femoral approach (TFA) combined with an internal transjugular approach (ITA) in the presence of very tight binding sites causing failure of VEA extraction or in cases of free-floating leads. Results From January 1997 to December 2014, we managed 2250 consecutive patients (1718 men, mean age 65.3 years) with 4114 leads (mean pacing period 71.8 months, range 1-576). PL were 3228 (1582 ventricular, 1391 atrial, 355 coronary sinus leads), DL were 786 (765 ventricular, 6 atrial, 15 superior vena cava leads). Removal was attempted in 4105 leads, since the technique was not applicable in 9 PL. Among these, 4019 leads were completely removed (97.9%), 44 (1.1%) partially removed, and 42 (1.0%) not removed. Among 4020 exposed leads, 625 were removed by manual traction (15.5%), 2998 by mechanical dilatation using the venous entry site (74.6%), 32 by femoral approach (FA) (0.8%), and 279 by ITA. Major complications occurred in 13 cases (0.6%): cardiac tamponade (12 cases, 2 deaths), hemotorax (1 death). Conclusion Mechanical single sheath extraction technique with multiple venous entry site approaches is effective, safe and has a good cost effective profile for pacing and ICD leads removal. TLR through the ITA increases the effectiveness and safety of the procedure in case of challenging leads