The Lead Extractor's Toolbox: A Review Of Current Endovascular Pacemaker And ICD Lead Extraction Techniques

Abstract

Recently introduced pacemaker leads float freely within the veins and myocardium. Later on, fibrous encapsulation of the lead develops 1. These adhesions not only occur at the lead tip but are commonly found anywhere along the whole length of the lead at sites where the lead is in contact with the vein or the myocardium 1,2,3,4. These adhesions hamper lead removal as tight scar tissue can withhold the leads during traction. This not only occurs at the level of the flings and tines of passive fixation leads but at any level of the lead body, especially at sites of unequal diameter for example electrodes and defibrillator coils. Further the lead tip is often larger than the lead body due to the fixation mechanism and adhering scar tissue and can become impacted on withdrawal in the narrow canal provided by the fibrous envelope. Force applied to leads is limited by the tensile strength of the insulation and conductor coils of the leads. They may severe with forceful traction, and denuded indwelling lead fragments have a higher incidence of thrombo-fibrotic complications and may maintain infection 5,6,7,8. Force is also limited by the impact of traction on the veins and myocardium. Unopposed traction can lead to invagination of the myocardium, myocardial rupture, arrhythmia, hypotension or avulsion of a tricuspid valve leaflet 9,10,11,12,13. Therefore, additional tools have been developed to assist in freeing the lead body from the adhesions as well as the lead tip from the myocardium, to prevent laceration of the myocardium and to provide enough room for the lead to be withdrawn whilst preventing disintegration of the lead. We describe the technical aspects of current endovascular techniques, the results, the complications and shortly discuss the indications.

Keywords

• pacemaker lead extraction