JCM | Free Full-Text | Stepwise Approach for Transvenous Lead Extraction in a Large Single Centre Cohort

JCM | Free Full-Text | Stepwise Approach for Transvenous Lead Extraction in a Large Single Centre Cohort

Although guidelines for TLE exist, there are no recommendations for a specific or systematic approach [4,5]. Every centre has an individual approach and uses different tools. A systematic approach from a less to a more invasive approach is more time consuming than a primary approach with a powered sheath, but can be associated with lower complication rates. We therefore sought to investigate an approach which systematically starts with a less invasive approach and increases severity step-by-step with a femoral snare as a bail-out strategy. Laser sheaths were not used; even though they have shown the highest success rates for TLE according to a large review by Buiten et al., they are also associated with the highest rates of mortality, as well as major and minor procedure-related complications. Complications due to the use of laser sheaths are even more frequent than with femoral access snares [7]. The use of laser sheaths can often only be cost-effective if used for every procedure in a centre [9,10]. We therefore sought to exclude laser sheaths in this stepwise approach as it did not seem feasible for a real-world stepwise approach.
Simple traction, mostly with a standard stylet inserted, is often used in leads implanted for a short time. The success rate for this less invasive approach in our cohort is comparable to data from the ELECTRa registry (31.5% in our cohort vs. 27.3% in the ELECTRa registry) [2]. Successful extraction with simple traction was associated with shorter lead dwelling time and active fixation leads, as also reported in a review by Buiten et al. [7]. Compared to other studies that reported success rates of 70–93% with simple traction for CS lead, our success rate for CS lead extraction with simple traction was significantly lower, with 25.8% [11,12,13]. Compared to those studies, the lead dwelling time in our cohort was longer (5.4 ± 4.8 years vs. 1.5–3.0 years), and our cohort consisted of a higher number of CRT-D systems compared to CRT-P systems. Longer lead dwelling time and more ICD leads present can lead to more frequent and more severe venous adhesions, meaning lower success rates for CS lead extraction with simple traction. For LLD and traction only, little data on success rates has been reported [7]. Our cohort is one of the largest so far, reporting a detailed analysis for this step. Our success rate is very comparable to studies with similar lead dwelling time and regular use of LLD and traction during the extraction procedure (42.7% in our cohort vs. 37% in data reported by Geselle et al. and Williams et al.) [11,14]. After the first two less invasive steps, we successfully extracted 58.7% of all leads identified for extraction without major complications. As these steps impose little risk with a relatively high success rate, it seems reasonable to advise trying these steps first in the majority of extraction procedures, especially for active fixation leads. With mechanical non-powered sheaths, we successfully extracted 84.1% of the leads that were not extracted during the first two steps. The success rate was lower compared to a very large cohort reported by Kutarski et al., which had a 95% success rate in 2049 patients [15]. Our success rate can be lower as we were able to escalate to the next step if extraction with mechanical non-powered sheaths was difficult. However, the major complication rate was higher in the data reported by Kutarski et al. (1.8% vs. 0.4% in our cohort). The higher complication rate can be due to longer lead dwelling time (86.3 months reported by Kutarski et al. vs. 64.3 months in our study) and a high dedication to successfully extracting leads by only using non-powered mechanical sheaths [15]. Both major complications in our cohort occurred during extraction using non-powered mechanical telescopic sheaths. As non-powered sheaths require manual rotation of the sheaths, an uneven, non-continuous rotation and traction can increase the risk of a major complication. With powered mechanical sheaths, we extracted 92.6% of leads that were not extractable before during the first three steps. Our success rate was higher than data reported by Zsigmond et al. [16]. Lead dwelling time was even longer in our cohort for patients in which a mechanical powered sheath was used (11.7 years in our cohort vs. 9.4 years reported by Zsigmond et al. [16]). Zsigmond et al. compared mechanical powered sheaths with laser powered sheaths as the first line tool and reported a crossover rate due to extraction failure of 19.5% for laser sheaths and 13% for mechanical powered sheaths. A significant number of crossovers were necessary due to severe adhesions at extracardiac levels [16]. Our high success rate can be explained by the stepwise approach having helped detach fibrous adhesions. For different manufacturers, operators did not report any relevant technical difference in handling or usability of the devices. Even though there was little data available to compare different manufacturers, we did not see a trend that might suggest one manufacturer’s sheath system was superior to another. Our stepwise approach appears to be as efficient as a crossover between two very invasive approaches with a lower complication rate (2.2–5.2% major complications and 8.7–12.5% minor complications vs. 0.4% major complications and 6.5% minor complications in our cohort) [16]. Procedural failure was accounted for in 1.1% of our patients. Additional use of laser sheaths can have helped in these cases. In our centre, we referred those patients to our cardiothoracic surgeons. We therefore recommend considering the use of laser sheaths in future stepwise approach extraction procedures.
Our total procedural success rate was lower compared to other large studies [17]. The possibility of ending the extraction procedure at the operator’s discretion if they determined that the major goal of the procedure had been achieved to avoid unnecessary risks, even if leads were abandoned, is a likely explanation. As expected, procedure time was longer in our cohort compared to the ELECTRa registry (83.0 vs. 103.4 min) [2]. However, in our opinion, the lower complication rate outweighs the longer procedure time.
Procedure-related major complication rates were low in our cohort compared to the ELECTRa registry (1.7% vs. 0.4% in our cohort) [2]. The stepwise approach, the possibility to end the extraction procedure at the operator’s discretion if the main extraction goal was achieved, and our experience as a high volume centre can be explanations. This agrees with a study by Bontempi et al. who reported a major complication rate of 0.6% in 973 patients with a stepwise approach [17]. Minor complication rates in our study were comparable to the ELECTRa registry (5.0% vs. 6.5% of patients in our cohort) [2]. Minor complications were associated with comorbidities or medication and not with the extraction strategy in our cohort. In order to avoid pocket hematoma, a short interruption of one antiplatelet agent in DAPT should be considered if possible. An interruption of ASA does not seem necessary as there only was a correlation for pericardial effusion, which did not require an intervention. According to our data, patients with renal insufficiency and history of ventricular arrhythmia need to be monitored closely during and after the procedure. A prolonged ECG monitoring for patients with history of ventricular arrhythmia seems reasonable.

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