Lead Extraction FAQs

Lead Extraction FAQs

How is lead extraction performed?

The procedure is performed under general anesthesia. A special IV is placed in an artery in the wrist or groin to monitor the blood pressure. Your skin is cleaned and prepped for the lead extraction and emergency open heart surgery in the rare event the need arises. For patients that are dependent on the pacing function of their device, a temporary pacing wire is placed through a vein in the groin. A guidewire is advanced from the groin to use a special balloon that can stop bleeding in the veins if needed. An attempt is made to remove the leads using gentle traction. If they cannot be removed, the leads are prepared for extraction using a laser or cutting sheath. Click on the following links to view animations of the Excimer laser sheath *** and Evolution cutting sheath *** courtesy Spectranetics® and Cook® Medical, respectively. If you have an infection, we wait to implant a new system until blood cultures drawn after the procedure show no further infection. If there is no infection and new leads are needed, they are implanted during the same procedure. Lead extraction procedures can last several hours. 

What are the risks of the lead extraction?

All heart procedures have inherent risk. Life-threatening complications can occur during lead extraction, including tearing the veins that the leads travel through or perforating the heart muscle. In rare instances, open heart surgery may be needed to repair the injury. In a large study in which 3,258 patients underwent lead extraction, 25 (0.8%) patients required emergency surgery or other interventions due to life-threatening complications.1 The procedural mortality associated with lead extraction is about 0.4%.2

What precautions do we take to perform lead extraction safely?

We perform our cases in a hybrid operating room that has the x-ray equipment needed to remove the leads noninvasively. The operating room  is equipped for emergency open heart surgery if necessary. In addition to a consultation with our electrophysiologist, each patient is also evaluated by a cardiothoracic surgeon prior to the case. The cardiothoracic surgeon and his or her team are immediately available if emergency open heart surgery is needed. In some centers this is not an option, and substantial delay can occur if there is an emergency. As an added precaution, in every case we also advance a guidewire through a vein in the groin to the area were the leads are extracted. This allows us to deploy a specially designed balloon that can stop bleeding if a vein tear occurred. 

What are alternatives to lead extraction?

Patients with an infection in the blood stream or at the pacemaker or ICD pocket often do not have an alternative to extraction because antibiotics usually cannot cure an infection in the presence of the foreign material in the body. The mortality associated with these infections usually exceeds the risk of extracting the leads. Patients that need extraction for indications that are not related to infection, have  an option to abandon leads and leave them in place. This often happens when a lead is malfunctioning or upgrade from a pacemaker to an ICD lead is needed. Studies have shown that this approach can make lead extraction more difficult and risky if it is needed in the future.3 In addition, abandoned leads can interfere with functioning leads, increase the risk of infection and occlusion of the veins, and make it more likely to have tricuspid valve regurgitation. For every patient the risk of leaving a lead in place needs to be weighed against the risk of lead extraction. For some patients, abandoning a lead is the right choice. 

What happens prior to the procedure?

You will meet with an electrophysiologist who will explain why lead extraction may be needed and review alternatives to the procedure as well as the associated risks and benefits. Consultation with a cardiothoracic surgeon is also performed. In some cases x-rays and other tests are ordered to prepare for the case.

How long will I stay in the Hospital?

Most patients spend one night at the hospital and are discharged the following morning. For patients with infection, we have to make sure there is no ongoing infection after extraction, and re-implant is often delayed at least 72 hours. Patients that depend on their device for pacing will have to stay in the hospital during this time period while nondependent patients can sometimes be discharged and return for implant at a later date. Patients with ICDs that are discharged before re-implant can wear an external defibrillator during the waiting period.

What is the recovery after lead extraction?

For uncomplicated cases the recovery is no different than after the initial implant. There may be mild pain and discomfort at the incision site that last for days to weeks. If a new lead or leads are implanted precautions are taken for several weeks to prevent the lead from dislodging. Follow up is usually 1 – 2 weeks after the procedure. 


References:
1. Brunner MP, Cronin EM, Wazni O, et al. Outcomes of patients requiring emergency surgical or endovascular intervention for catastrophic complications during transvenous lead extraction. Heart Rhythm. 2014;11(3)419-25.
2. Wazni O, Epstein LM, Carillo RG, et al. Lead extraction in the contemporary setting: the LExICon study: an observational retrospective study of consecutive laser lead extraction. J Am Coll Cardiol. 2010;55(6):579-586.
3. Hussein A, Tarakji KG, Martin DO, et al. Cardiac implantable device infections: added complexity and suboptimal outcomes with previously abandoned leads. J Am Coll Cardiol. 2016;1(3).