Removal of leads broken during extraction: A comparison of different approaches and tools
Andrzej Kutarski MD
Department of Cardiology, Medical University of Lublin, Lublin, Poland
Search for more papers by this authorWojciech Jacheć MD
2nd Department of Cardiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
Search for more papers by this authorRadosław Pietura MD
Department of Radiography, Medical University of Lublin, Lublin, Poland
Search for more papers by this authorPaweł Stefańczyk MD
Department of Cardiology, The Pope John Paul II Province Hospital, Zamość, Poland
Search for more papers by this authorJarosław Kosior MD
Department of Cardiology, Masovian Specialistic Hospital of Radom, Radom, Poland
Search for more papers by this authorMarek Czakowski MD, PhD
Department of Cardiac Surgery of Medical University, Medical University of Lublin, Lublin, Poland
Search for more papers by this authorSebastian Sawonik MD
Department of Cardiology, Medical University of Lublin, Lublin, Poland
Search for more papers by this authorŁukasz Tułecki MD, PhD
Department of Cardiac Surgery, The Pope John Paul II Province Hospital, Zamość, Poland
Search for more papers by this authorCorresponding Author
Dorota Nowosielecka MD, PhD
Department of Cardiology, The Pope John Paul II Province Hospital, Zamość, Poland
Department of Cardiac Surgery, The Pope John Paul II Province Hospital, Zamość, Poland
Correspondence Dorota Nowosielecka, MD,PhD, Department of Cardiac Surgery, The Pope John Paul II Province Hospital, 22-400 Zamość, Al. Jana Pawła II 10, Poland.
Email: [email protected]
Search for more papers by this authorAndrzej Kutarski MD
Department of Cardiology, Medical University of Lublin, Lublin, Poland
Search for more papers by this authorWojciech Jacheć MD
2nd Department of Cardiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
Search for more papers by this authorRadosław Pietura MD
Department of Radiography, Medical University of Lublin, Lublin, Poland
Search for more papers by this authorPaweł Stefańczyk MD
Department of Cardiology, The Pope John Paul II Province Hospital, Zamość, Poland
Search for more papers by this authorJarosław Kosior MD
Department of Cardiology, Masovian Specialistic Hospital of Radom, Radom, Poland
Search for more papers by this authorMarek Czakowski MD, PhD
Department of Cardiac Surgery of Medical University, Medical University of Lublin, Lublin, Poland
Search for more papers by this authorSebastian Sawonik MD
Department of Cardiology, Medical University of Lublin, Lublin, Poland
Search for more papers by this authorŁukasz Tułecki MD, PhD
Department of Cardiac Surgery, The Pope John Paul II Province Hospital, Zamość, Poland
Search for more papers by this authorCorresponding Author
Dorota Nowosielecka MD, PhD
Department of Cardiology, The Pope John Paul II Province Hospital, Zamość, Poland
Department of Cardiac Surgery, The Pope John Paul II Province Hospital, Zamość, Poland
Correspondence Dorota Nowosielecka, MD,PhD, Department of Cardiac Surgery, The Pope John Paul II Province Hospital, 22-400 Zamość, Al. Jana Pawła II 10, Poland.
Email: [email protected]
Search for more papers by this authorDisclosures: None.
Abstract
Background
Extraction of a broken lead fragment (BLF) has received scant attention in the literature.
Methods
Retrospective analysis was to compare the effectiveness of different approaches and tools used for BLF removal during 127 procedures.
Results
A superior approach was the most popular (75.6%), femoral (15.7%) and combined (8.7%) approaches were the least common. Of 127 BLFs 78 (61.4%) were removed in their entirety and BLF length was significantly reduced to less than 4 cm in 21 (16.5%) or lead tip in 12 (9.4%) cases. The best results were achieved when BLFs were longer (>4 cm) (62/93 66.7% of longer BLFs), either in the case of BLFs free-floating in vascular bed including pulmonary circulation (68.4% of them) but not in cases of short BLFs (20.0% of short BLFs). Complete procedural success was achieved in 57.5% of procedures, the lead tip retained in the heart wall in 12 cases (9.4%) and short BLFs were found in 26.0%, whereas BLFs >4 cm were left in place in four cases (3.1%) of procedures only. There was no relationship between approach in lead remnant removal and long-term mortality.
Conclusions
(1) Effectiveness of fractured lead removal is satisfactory: entire BLFs were removed in 61.4% (total procedural success—57.5%, was lower because five major complications occurred) and BLF length was significantly reduced in 26.0%. (2) Among the broken leads, leads with a long stay in the patient (16.3 years on average), passive leads (97.6%) and pacemaker leads 92.1% are significantly more common, but not ICD leads (only 7.9% of lead fractures) compared to TLE without lead fractures. (3) Broken lead removal (superior approach) using a CS access sheath as a “subclavian workstation” for continuation of dilatation with conventional tools deserves attention. (4) Lead fracture management should become an integral part of training in transvenous lead extraction.
Open Research
DATA AVAILABILITY STATEMENT
Data are available upon request to authors.
Supporting Information
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Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.
REFERENCES
- 1Wilkoff BL, Love CJ, Byrd CL, et al. Transvenous lead extraction: Heart Rhythm Society expert consensus on facilities, training, indications, and patient management: this document was endorsed by the American Heart Association (AHA). Heart Rhythm. 2009; 6: 1085-1104.
- 2Kusumoto FM, Schoenfeld MH, Wilkoff BL, et al. 2017 HRS expert consensus statement on cardiovascular implantable electronic device lead management and extraction. Heart Rhythm. 2017; 14: e503-e551.
- 3Bongiorni MG, Burri H, Deharo JC, et al. 2018 EHRA expert consensus statement on lead extraction: recommendations on definitions, endpoints, research trial design, and data collection requirements for clinical scientific studies and registries: endorsed by APHRS/HRS/LAHRS. Europace. 2018; 20:1217.
- 4Byrd CL, Wilkoff BL, Love CJ, et al. Intravascular extraction of problematic or infected permanent pacemaker leads: 1994–1996. Pacing Clin Electrophysiol. 1999; 22: 1348-1357.
- 5Bongiorni MG, Giannola G, Arena G, et al. Pacing and implantable cardioverter-defibrillator transvenous lead extraction. Italian Heart J. 2005; 6: 261-266.
- 6Gomes S, Cranney G, Bennett M, Li A, Giles R. Twenty-year experience of transvenous lead extraction at a single centre. Europace. 2014; 16: 1350-1355.
- 7Kutarski A, Czajkowski M, Pietura R, et al. Effectiveness, safety, and long-term outcomes of non-powered mechanical sheaths for transvenous lead extraction. EP Europace. 2018; 20: 1324-1333.
- 8Diemberger I, Migliore F, Biffi M, et al. The “Subtle” connection between development of cardiac implantable electrical device infection and survival after complete system removal: an observational prospective multicenter study. Int J Cardiol. 2018; 250: 146-149.
- 9Jacheć W, Polewczyk A, Segreti L, Bongiorni MG, Kutarski A. To abandon or not to abandon: late consequences of pacing and ICD lead abandonment. Pacing Clin Electrophysiol. 2019; 42: 1006-1017.
- 10Kennergren C, Bucknall CA, Butter C, et al. Laser-assisted lead extraction: the European experience. EP Europace. 2007; 9: 651-656.
- 11Roux JF, Pagé P, Dubuc M, et al. Laser lead extraction: predictors of success and complications. Pacing Clin Electrophysiol. 2007; 30: 214-220.
- 12Wazni O, Epstein LM, Carrillo RG, et al. Lead extraction in the contemporary setting: the LExICon study: an observational retrospective study of consecutive laser lead extractions. J Am Coll Cardiol. 2010; 55: 579-586.
- 13Brunner MP, Cronin EM, Duarte VE, et al. Clinical predictors of adverse patient outcomes in an experience of more than 5000 chronic endovascular pacemaker and defibrillator lead extractions. Heart Rhythm. 2014; 11: 799-805.
- 14Hussein AA, Tarakji KG, Martin DO, et al. Cardiac implantable electronic device infections. JACC Clin Electrophysiol. 2017; 3: 1-9.
- 15Artus A, Mansourati J, Fatemi M, et al. Efficacy and safety of the new TightRail™ mechanical sheath for transvenous lead extraction: results of a French multicenter study. J Cardiovasc Electrophysiol. 2022; 33: 731-737.
- 16Starck CT, Gonzalez E, Al-Razzo O, et al. Results of the Patient-Related Outcomes of Mechanical lead Extraction Techniques (PROMET) study: a multicentre retrospective study on advanced mechanical lead extraction techniques. EP Europace. 2020; 22: 1103-1110.
- 17Yap SC, Bhagwandien RE, Theuns DAMJ, et al. Efficacy and safety of transvenous lead extraction using a liberal combined superior and femoral approach. J Interv Card Electrophysiol. 2021; 62: 239-248.
- 18Zhou X, Ze F, Li D, et al. Transfemoral extraction of pacemaker and implantable cardioverter defibrillator leads using Needle's Eye Snare: a single-center experience of more than 900 leads. Heart Vessels. 2020; 35: 825-834.
- 19Nof E, Bongiorni MG, Auricchio A, et al. Comparison of outcomes in infected cardiovascular implantable electronic devices between complete, partial, and failed lead removal: an ESC-EHRA-EORP ELECTRa (European Lead Extraction ConTrolled) registry. EP Europace. 2019; 21: 1876-1889.
- 20Calvagna GM, Romeo P, Ceresa F, Valsecchi S. Transvenous retrieval of foreign objects lost during cardiac device implantation or revision: a 10-year experience. Pacing Clin Electrophysiol. 2013; 36: 892-897.
- 21Kutarski A, Pietura R, Czajkowski M. Breakage of extracted leads: another management option. Kardiol Pol. 2012; 70: 307-312.
- 22Kutarski A, Chudzik M, Oszczygieł A, Wranicz JK. Extraction of abandoned, potentially dangerous lead with uncovered proximal ending: a case report and method description. Cardiol J. 2012; 19: 192-196.
- 23Kutalek SP, Pace JN, Kussmaul W. Management of distal electrode detachment during lead extraction. Pacing Clin Electrophysiol. 1997; 20: 985-988.
- 24Marrazzo N, Ugolotti U, Villani GQ, Groppi F, Castellini P, Capucci A. Endocardial defibrillation lead extraction: an unusual case of entrapment. Pacing Clin Electrophysiol. 2003; 26: 2036-2038.
- 25Kutarski A, Małecka B, Ząbek A, Pietura R. Broken leads with proximal endings in the cardiovascular system: serious consequences and extraction difficulties. Cardiol J. 2013; 20: 161-169.
- 26Sochman J, Bytesnik J, Skalsky I, Peregrin JH. Percutaneous extraction of a severed and frayed permanent pacing lead. Pacing Clin Electrophysiol. 2004; 27: 412-414.
- 27Raatikainen MJP, Perala J, Lahtinen J. Successful defibrillator lead remnant extraction from right ventricle using a steerable transseptal sheath and a basket retriever. Europace. 2009; 11: 1238-1240.
- 28Kutarski A, Chudzik M, Tomaszewski A, et al. Difficult dual-stage transcutaneous multiple lead extraction with loss of external silicone tube of broken lead. Cardiol J. 2013; 20: 94-99.
- 29Yüksel S, Yaşar E, Demircan S. Successful extraction of broken pacemaker leads by using a snare-loop device and radiofrequency ablation catheter. Anadolu Kardiyol Derg. 2013; 13: E41-E42.
- 30Tanawuttiwat T, Cheng A, Rickard J, Chow GV, Sciortino CM, Brinker J. Successful extraction of right ventricular lead remnants using the FlexCath® steerable sheath. J Interv Card Electrophysiol. 2016; 45: 107-110.
- 31Isawa T, Yamada T, Honda T, Yamaya K, Ootomo T. Spaghetti twisting” technique: a novel method of catching pacemaker leads using a needle's eye snare. Clin Case Rep. 2017; 5: 1269-1273.
- 32Stefańczyk P, Borzęcki W, Tułecki Ł, et al. To replace or to abandon and implant a new lead? Conservative approach creates new challenges (and risks) for the patients in future. Should we still wait for class 1 indications? Case report and discussion of the problem. Heart Beat. 2019; 4: 125-128.
10.24255/hbj/105890 Google Scholar
- 33Imaeda S, Katsumata Y, Kimura T, Takatsuki S. Successful percutaneous extraction of a remnant floating pacemaker lead. BMJ Case Rep. 2021; 14:e243128.
- 34Stefanczyk P, Polewczyk A, Nowosielecka D, et al. Lead extraction and re-extractions-inherent parts of permanent pacing in children and young adults. J Biomed Res Environ Sci. 2022; 3: 221-226.
10.37871/jbres1426 Google Scholar
- 35Mayer E, Saggau W, Welsch M, et al. Late pulmonary embolization of a retained pacemaker electrode fragment after attempted transatrial extraction. Thorac Cardiovasc Surg. 1985; 33: 128-130.
- 36Golzio PG, Bongiorni MG, Chiribiri A, Franco E. Extraction of the inner coil of a pacemaker lead slid into the pulmonary artery. Pacing Clin Electrophysiol. 2007; 30: 273-275.
- 37Golzio PG, Bongiorni MG, Giuggia M, Vinci M, Gazzera C, Breatta AD. Retrieval of pacemaker lead tip embolized into the distal pulmonary arterial bed during extraction procedure. Pacing Clin Electrophysiol. 2007; 30: 1558-1561.
- 38Kutarski A, Polewczyk M, Pietura R. A rare complication of transvenous lead extraction - pulmonary embolization with a broken distal lead fragment. Heart Beat J. 2016; 1: 31-34.
10.24255/hbj/67869 Google Scholar
- 39Jacheć W, Nowosielecka D, Ziaja B, Polewczyk A, Kutarski A. LECOM (Lead Extraction COMplexity): a new scoring system for predicting a difficult procedure. J Clin Med. 2023; 12: 7568.
- 40Kutarski A, Jacheć W, Nowosielecka D, Polewczyk A. Unexpected procedure difficulties increasing the complexity of transvenous lead extraction: the single Centre experience with 3721 procedures. J Clin Med. 2023; 12(8): 2811.
- 41Dieuzaide P, Savon N, Chalvidan T, LeTallec L, DeHaro JC, Djiane P. A complication of pacemaker lead extraction: paradoxical embolism of a lead fragment in a leg artery. Pacing Clin Electrophysiol. 1998; 21: 2699-2700.
- 42Yildirir A, Batur MK, Oto A. Embolization of pacing electrode fragment into the superolateral vein in the spinal canal causing root compression. J Cardiovasc Electrophysiol. 2002; 13: 290-291.
- 43Kao HL, Wang SS, Chen WJ, Huang SKS, Lee YT. Migration of a fractured retention wire in the pulmonary artery from an active fixation atrial lead. Pacing Clin Electrophysiol. 1995; 18: 1966-1967.
- 44Oge HK, Aydin S, Cagavi F, Benli K. Migration of pacemaker lead into the spinal venous plexus: case report with special reference to Batson's theory of spinal metastasis. Acta Neurochir. 2001; 143: 413-416.
- 45Starck CT, Caliskan E, Klein H, Steffel J, Falk V. Impact of a femoral snare approach as a bailout procedure on success rates in lead extractions. Interact Cardiovasc Thorac Surg. 2014; 18: 551-555.
- 46Isawa T, Honda T, Yamaya K, Taguri M. Predictors of the need for supportive femoral approach during transvenous extraction of pacemaker and defibrillator leads in Japanese patients. J Arrhythm. 2020; 36: 746-754.
- 47Tułecki Ł, Jacheć W, Polewczyk A, et al. Assessment of the impact of organisational model of transvenous lead extraction on the effectiveness and safety of procedure: an observational study. BMJ Open. 2022; 12:e062952.
- 48Bracke FA, Rademakers N, Verberkmoes N, Van't Veer M, van Gelder BM. Comparison between laser sheaths, femoral approach and rotating mechanical sheaths for lead extraction. Neth Heart J. 2022; 30: 267-272.
