Pacemaker lead complications: when is extraction appropriate and what can we learn from published data?

Indications for extraction of chronically implanted pacemaker leads have been classified as mandatory, necessary, or discretionary.1 2In published reports as well as in clinical practice, most indications cited are non-vital. These indications are often based on clinical judgement, even in published policy statements.3 We therefore reviewed published work on this subject, starting from the Pubmed database, in an attempt to provide an evidence base for the benefits of lead extraction. We begin with a brief overview of the results and complications of current extraction techniques. Recently, comprehensive endovascular techniques have been developed for pacemaker lead extraction.2 4 5 In the superior vena cava approach, a locking stylet is introduced into the lead and locked close to the distal electrode in order to apply traction directly to the tip.6 If gentle traction is not successful, telescoping sheaths can be advanced over the lead to disrupt fibrous binding of the lead to veins or myocardium. When necessary, the tip of the lead is freed by countertraction, the sheath being positioned against the myocardium to prevent inversion during traction on the lead. Recently, a laser sheath has been introduced which uses photoablation to disrupt the fibrous bindings instead of mechanical force.7-10 In the transfemoral approach, the pacing lead is grabbed with a deflecting guide wire or retriever through a long sheath inserted from the femoral vein.7 11 The proximal end of the lead is pulled down from the subclavian vein. Then the outer sheath is advanced over the lead to disrupt the scar tissue, as with the superior approach. When the myocardium is reached countertraction is applied. Table 1 summarises the results of the different extraction techniques. With the use of only locking stylets, Alt et al achieved total removal of 81% of 150 leads, partial …